MEDICAL CLASSICS
vol. 2 . September, 1937 no. 1
CONTENTS
Portrait of Joseph Lister -------- 4
Joseph Lister
Biography - -- -- -- -- -- 5
Introduction to the Writings of Lister - - 7
Bibliography - -- -- -- -- - 9
Bibliography of Biographies - ----- 15
On a New Method of Treating Compound Frac-
ture, Abscess, Etc., with Observations on the
Conditions of Suppuration. Joseph Lister,
Esq., F.R.S.- - -- -- -- -- -28
On the Antiseptic Principle in the Practice of
Surgery. Joseph Lister, Esq., F.R.S.- - - 72
On the Effects of the Antiseptic System of Treat-
ment upon the Salubrity of a Surgical Hospital.
Joseph Lister, Esq., F.R.S. ------ 84
JOSEPH LISTER
As he appeared in 1895, aged 68
MEDICAL CLASSICS
vol. ii September, 1937 xo. 1
Joseph Lister
BIOGRAPHY
1827 Born April 5, son of Joseph Jackson and Isabella (Harris)
Lister. Had three brothers and two sisters. His
father was a Quaker and a wine merchant whose hobby
was the study of optics and the making of lenses. Al-
though largely self-taught he was given a fellowship in
the Royal Society in 1S32. Joseph Lister attended
school at Hitchcn and at Grove House, Tottenham.
He was a precocious boy, read the Latin classics and
wrote several papers on natural history.
1844 Age 17. Entered University College, London, because it
had no religious requirements or affiliations. After 3
years he received the degree of A.B.
1848 Age 21. Began study of medicine. Anesthetics were just
being introduced.
1852 Age 25. Given the degree of M.B. at the University of
London and a Fellowship of the Royal Society of
Surgeons.
1853 Age 26. Lister was advised by his teacher William
Sharpey to visit several medical centers, among them
Edinburgh. In the latter city, Lister was cordially
received by Syme, the leading surgeon of Britain, and
given work in Syme’s wards.
1854 Age 27. Lister became assistant surgeon in the Infirmary
and was busy in teaching.
1856 Age 29. Lister married Syme’s daughter, Agnes, after
resigning from the Quakers and becoming a member
5
6 Medical Classics
of the Church of England. After a honeymoon of
three months spent in travel on the continent where
Lister met the leading medical men of his time, he
began practice in Edinburgh.
1860 Age 33. Appointed professor of surgery in the Uni-
versity of Glasgow.
1861 Age 34. Became surgeon to the Royal Infirmary.
1865 Age 38. While studying suppuration, became acquainted
with Pasteur’s work on putrefaction.
1867 Age 40. Wrote first articles on antiseptic treatment of
wounds.
1869 Age 4a. Elected professor of surgery at Edinburgh when
Syme resigned because of poor health. Reduced his
lectures to two a week, often had 170 students in a
class. Continued work on antiseptic methods.
1875 Age 4^- Traveled extensively in Europe.
1876 Age 49. Visited the United States and was made Presi-
dent of the Surgical Section of the International
Medical Congress in Philadelphia.
1877 Age 50. Accepted newly created chair of clinical surgery
at King’s College, London.
1878 Age 51. A juror at the University Exhibition at Paris.
1883 Age 56. Made a Baronet.
1891 Age 64. Instrumental in establishing the British Insti-
tute for Preventive Medicine (later rc-named after
Lister).
1892. Age 65. Retired from his professorship at King’s College.
Age 66. Lady Lister died of pneumonia while traveling
in Italy. They had no children.
1895 Age 68. Elected President of the Royal Society.
1897 Age 70. Again traveled widely in the United States and
Canada. Was elevated to the peerage.
1909 Age 8a. Sight and hearing became impaired, could
neither read nor write.
191a Age 85. Died on February ia. Following his wish, he
was not buried in Westminster Abbey, but was interred
beside his wife at the West Hampstead Cemetery.
7
Joseph Lister
“Lister was almost worshiped by his patients. He was so
extremely sympathetic, so gracious in his manner, and so atten-
tive to all their wants. His thoughtful face showed obvious
mastery of himself and of his situation.” P. F. Clark.
INTRODUCTION TO THE WRITINGS OF LISTER
Joseph Lister takes his place with Pare and John Hunter as
the third of the three greatest surgeons of all time because of a
fortunate series of circumstances.
Lister’s father, Joseph Jackson Lister, although a wine mer-
chant by trade, did a great amount of work in developing optical
lenses. He taught his son the use of the microscope and devel-
oped in him an interest in objects of nature. From his father,
also, Joseph inherited a love for the classics. At an early age he
was able to read these classics in the original Latin and with
his father’s aid wrote several papers on subjects in natural
history.
The second factor influencing the development of Joseph
Lister was his attendance at medical school at the time when
anesthesia was being introduced into surgery. Before the use
of ether and chloroform the surgeon had to perform his opera-
tions in as short a time as possible. Minutes were as years to
the patient. The surgeon could not do a careful, painstaking
operation but had to work rapidly. After anesthesia, the next
great step to be made was the control of infection. Most opera-
tions were followed by suppuration and discharge of pus. Those
were the days of “laudable” pus when it was thought that
a discharge of matter was necessary for the proper healing of
wounds. Hippocrates and, several centuries later, Henri de
Mondeville, had taught that healing without pus was desirable
but their teaching had little influence. Perhaps many surgeons
wished their patients to be without infection and pus formation,
but since no one knew the cause of infection, no one knew how
to prevent it.
A third factor in the development of Joseph Lister was his
visit to several medical centers as soon as he had been graduated
from medical school. His wise teacher, William Sharpey, ad-
8 Medical Classics
vised this completion of his education. In Edinburgh Lister,
then only twenty-six years of age, was cordially received by
James Syme, at that time the leading surgeon of the British
Isles. Lister became an assistant to Syme and two years later
married his daughter.
From the very beginning of his residence in Edinburgh, Lister
was engaged in research on inflammation, coagulation of blood
and infection. He published several papers on these subjects.
He found his hospital wards terribly affected with septicemia,
pyemia, erysipelas and hospital gangrene. In 1S66 his own cases
of amputation had a mortality of 45 per cent.
In the course of his studies and eagerness to find a way to
control infection, Lister came upon an article recently published
by the famous scientist, Louis Pasteur. Pasteur had proven
that there is no such thing as spontaneous generation and that
all putrefaction is due to the growth of living organisms or bac-
teria. Lister at once recognized the value of applying Pasteur’s
discovery to human beings to prevent or control infection.
Because Pasteur’s method of sterilization by heat could not
be applied to living tissues, Lister sought a chemical which would
prevent contamination of wounds by organisms in the air. He
was acquainted with the problem of the village fathers of a
nearby town, Carlyle, where the populace was aroused because
of the odor of the local sewage disposal system. The town
board of Carlyle had found that the addition of a small amount
of carbolic acid to the sewage prevented putrefaction and thus
abolished the odor. Lister determined to apply carbolic acid
to his cases of compound fracture and thus, by preventing de-
composition of the tissue, have primary union of the injured
bone and lacerated tissues.
The story of his experiences in instituting this treatment and
the results he obtained in his first cases is republished here.
These papers of Lister thus inaugurated a new era in surgery,
the antiseptic era. From this period there was a rapid develop-
ment to the aseptic period in which, by mechanical and chemical
means, everything which comes in contact with the patient’s
tissues at the time of operation is sterilized. No bacteria are
Joseph Lister 9
present to cause putrefaction and the horrors of surgery of
Lister’s day.
BIBLIOGRAPHY OF WRITINGS
1. Observations on the muscular tissue of the skin. 7 pp., 8°,
Lond., W. Clowes & Sons, 1853.
1 . Observations on the contractile tissues of the iris. Quart.
J. Micr. Sc., Lond., 1:3-11, 1853.
3. On a remarkable case of hydrocele. Edinb. M. J., 2: 236-
239, 1856.
4. Case of pedunculated exostosis. Ibid., 2: 1034, 1857.
5. On the early stages of inflammation. Proc. Roy. Soc.,
Lond., 8: 581-587, 1851. Also: Edinb. M. J., 3: 656-660,
1858.
6. On the minute structure of involuntary muscular fibre.
Tr. Roy. Soc. Edinb., 21: 549-557, 1857.
7. On spontaneous gangrene from arteritis and on the causes
of coagulation of the blood in diseases of the blood-vessels.
Edinb. M. J., 3: 893-907, 1858.
8. Further experiments on the coagulation of the blood. (Brief
note) Ibid., 3: 1049-1050, 1858.
9. Case of ligature of the brachial artery, illustrating the per-
sistent vitality of the tissues. Ibid., 4: 1 19-120, 1858.
10. Example of mixed aortic aneurism. Case. Ibid., 4: 546,
1858.
11. Preliminary account of an inquiry into the function of the
visceral nerves, with special reference to the so-called
inhibitory system. Proc. Roy. Sc. Lond., 9: 367-380,
1858.
12. Contributions to physiology and pathology; an inquiry
regarding the parts of the nervous system which regulate
the contractions of the arteries; On the cutaneous pig-
mentary system of the frog; On the early stages of inflam-
mation. Phil. Trans. 148: 607-625; 627-643; 645-701,
1 858-
13. Observations on the structure of nerve-fibers. With William
Turner. Quart. J. Micr. Sc., Lond., 8: 3-8, 1859.
io Medical Classics
14. Case of amputation of leg (railway accident). Exhibition
of needle to facilitate application of silver wire sutures.
Edinb. M. J., 4: 952-954, 1S59.
15. Notice of further researches on coagulation of blood. Ibid.,
5: 536-40, 1859. Also: Proc. Roy. Soc., Load., 12:
580-611, 1862-63. Also: Lancet, 35: 281-91, 1864.
16. Excision of wrist for caries. Lancet, l: 306-316, 1865.
17. On a new method of treating compound fractures, abscess,
etc., with observation on the condition of suppuration.
Lancet, 1: 326-329; 357 - 359 ? 387-389; 507-509; 2: 95-96,
1867. Also: London Lancet, i: 364-373; 4J8; 622-624,
1867. Also, in German: Klassiker der Mcdizin, vol. 1 7,
Leipzig, J. A. Barth, 1912.
18. On the antiseptic principle in the practice of surgery. Brit.
M. J., 2: 246-248, 1867. Also: Lancet, 2: 353"668, 1867.
Also: London Lancet, 1:741-745, 1867. Also in: Epoch-
Making Contributions to Medicine, by C. N. B, Camac,
pp. 9-20, Phila., Saunders, 1909. Also, in German:
Klassiker dcr Mcdizin, vol. 17, Leipzig, J. A. Barth, 1912.
19. Contribution to antiseptic treatment in surgery; an address.
Brit. M. J., 2: 53-56; 101-102; 461-463; 515-517, 1868;
i: 301-304, 1869. Also, in German: Klassiker dcr Mcdi-
zin, vol. 17, Leipzig, J. A. Barth, 1912.
20. Illustrations of the antiseptic system of treatment in surgery.
Lancet, 1: 92-94, 1868.
21. Observations on ligature of arteries on the antiseptic system.
Lancet, 40: 289-295, 1869.
22. Introductory lecture delivered in the University of Edin-
burgh, Nov. 8, 1869. 22 pp., 8°, Edinburgh, Edmonton iv*
Douglas, 1869.
23. On the effects of the antiseptic system of treatment upon the
salubrity of a surgical hospital. London Lancet, 1: 194 -
200, 1870.
24. Remarks on a case of compound dislocation of the ankle
with other injuries, illustrating the antiseptic system of
treatment. Ibid., 360-368, 1870.
25. The Glasgow infirmary and the antiseptic treatment.
Lancet, 1: 210-21 1, 1870.
Joseph Lister n
26. Further evidence regarding effects of the antiseptic treat-
ment upon the salubrity of a surgical hospital. Ibid.,
287-289, 1870.
27. A method of antiseptic treatment applicable to wounded
soldiers in the present war. Brit. M. J., Lond., 2: 243-
244, 1870.
28. Case of dislocation of the hip-joint, downwards and inwards,
reduced by manipulation. Edinb. M. J., 16: 148, 1871.
29. Address in surgery (antiseptic treatment of wounds). Brit.
M. J., Lond., 2: 225-233, 1871. Also: Jour, de Med.,
Chir. and Pharmacol., Brux., 53: 287; 407, 1871; 54:
33-46, 1872..
30. On some cases illustrating the results of excision of the wrist
for caries, treatment of deformity from contracted cicatrix,
and antiseptic dressing under circumstances of difficulty,
including amputation at the hip-joint. Edinb. M. J.,
17: 144, 1872.
31. A contribution to the germ theory of putrefaction and other
fermentative changes, and to the natural history of
Torulae and bacteria. Tr. Roy. Soc. Edinb., 27: 313—
344, 1873.
32. A further contribution to the natural history of bacteria
and the germ theory of fermentative changes. Quart. J.
Micr. Sc., Lond., n.s. 13, 1873.
33. On a case of rupture of the axillary artery in an attempt to
reduce a dislocation of the shoulder. Edinb. M. J., 18:
829-831, 1873.
34. Cases presented; omental hernia; tumor of femor; fibrous
tumor; apparatus for producing an antiseptic spray.
Ibid., 20: 69-73, 1874.
35. Case of rodent ulcer. Ibid., 268-270.
36. Cases in which antiseptics were used. Ibid., 55 ^ _ 557 *
37. Demonstration of antiseptic surgery before members of the
British Medical Association in the operating theatre of
the Royal Infirmary. Ibid., 21: 193-205; 481-487, 1875.
38. Principii et applicazione del metodo antisettico. Indi-
pendente, Torino, 26: 438-443, 1875.
12 Medical Classics
39. On recent improvements in the details of antiseptic surgery.
Lancet, I: 365-367; 401-402; 434-436; 468-470; 603-605;
7 1 7—7 1 9 ; 787-789, 1875. Also: London Lancet, 1: 269-
273; 3/9'3 2 7; 375-380, 1875.
40. Antiseptic surgery. Trans. Intcrnat. Med. Cong., Phila.,
PP- 535-544. ^76.
41. The antiseptic method of dressing open wounds. Med. Rcc.,
N. Y. 2: 695, 1876.
4 2. Graduation address at Edinburgh University. Edinb. M. J.,
22: 280-284, 1876.
43. Address in surgery. Ibid., 464-467.
44. Sur la m£thodc antiseptique. Bull, et mem. Soc. dc. cbir.
de Par., 4: 421-426, 1878.
45. Clinical lecture on a case of excision of the knee-joint and
on horse-hair as a drain for wounds. Lancet, j : 5-9,
1878.
46. A case of multiple papillomatous growths in the larynx,
extirpated by complete laryngotomy; removal of the whole
length of both true and false vocal cords; preservation of
the voice; coexistence of thoracic aneurysm. With J. B.
Yeo. Tr. Clin. Soc., Lond., 11:104-113, 1S78. Also:
Med. Rec., N. Y., 16: 117, 1879.
47. A demonstration in antiseptic surgery. Dublin Jour. Med.
Soc., 3 s., 68: 97-114, 1879.
48. Excision of elbow-joint. Case. Med. Times & Gaz., t:
175, 1879.
49. Stricture; fistula in perineo; embolism of both limbs, Ibid.,
175, 1879.
50. Remarks on dressing. Ibid., 2: 502, 1879.
51. Ueber antiseptische Wundbchandlung. Allg. Wien. Med.
Zeitg., 24: 395, 1879. Also: Mcd.-Chir. Centralbl., Wien.,
14: 578, 1879.
52. Mr. Syme’s treatment of incised wounds. (Letter). Lan-
cet, 1: 28-29, 1879.
53. Clinical lecture illustrating antiseptic surgery. Lancet, 2:
901-905, 1879. Also: Boston M. & S. J., 102: 116; 140-
142; 1880.
Joseph Lister 13
54. An address on the influence of position upon local circula-
tion. Brit. M. J., 1 : 923-92 6, 1879.
55. Mr. Spence on surgical statistics. Ibid., i: 237-239; 276-
278, 1880.
56. Gelatinous degeneration of knee-joint. Med. Times & Gaz.,
1: 579, 1880.
57. Lecture illustrating antiseptic surgery. London Lancet,
1: 493-500, 1880.
58. Remarks on microorganisms; their relation to disease. Clin.
News, Phila., i: 469-472, 1880. Also: Quart. J. Micr.
Soc., n.s. 21: 330-342, 1881. Also: Lancet, 2: 695-698,
1881. Also: London Lancet, i: 1-5, 1882. Also: Wien,
med. Bl., 4: 1385; 1420; 1449, 1881.
59. A series of cases of mammary diseases. Brit. M. J. 2: 777-
779) 1881.
60. An address on the treatment of wounds. Lancet, 2: 8 63-
866; 901-903, 1881.
61. President’s address (on catgut ligature). Tr. Clin. Soc.,
Lond., 14: xliii-lxiii. Also: Lancet, i: 201-206; 275,
1881. Also: Brit. M. J., i: 183-185; 219-221, 1881.
Also: Berl. lclin. Wochenschr., 18: 177; 194, 1881.
62. Gunshot wound of left forearm. Med. Times & Gaz., 2:
660, 1882.
63. Sul trattamento delle ferite. Discorso pronunciato nella
serione chirurgica del congress o medico internazionale al
terminare della discussione sulT argomento — 8 Agosto,
1881. Trad, dall’inglese del dott. Gregorio Fedeli.
Raccoglitore med., 1882. Also: Forli, tip. Democratica,
22 pp., 8°, 1882.
64. Chirurgie antiseptique et theorie des germes. Oeuvres
reunies de Traduction du Dr. Gustave Borginon.
xvi, 5-635 pp., 8°, Paris, A. Delahaye & E. Lecrosnier,
1882.
65. An address on the treatment of fracture of the patella. Brit.
M. J., 2: 855-860, 1 883.
66. An address on corrosive sublimate as a surgical dressing.
Lancet, 2: 723-728, 1884. Also: Brit. M. J., 2: 803-807,
1884. Also: Wien. Med. Bl., 7: 1375; r 4 12 ; J 44 8 > i88 4-
14 Medical Classics
67. An address on a new antiseptic dressing. Brit. M. J., 2:
1025-1029, 1889. Also: Illust. M. News, 5: 125-127,
1889. Also: Lancet, -1943-947, 1889. Also: Med. Rcc.,
N. Y., 36: 561-566, 1889. Also: Wien. Med. HI., 12:
7 2 35 74L 1889.
68. On two eases of long-standing dislocation of both shoulders
treated by operation. Lancet, 1:1, 1890. Also: North.
Lancet, Winnipeg, 3: 155-161, 1889-90. Also, abstr.:
Tr. Hunter. Soc. Lond., pp. 91-94, 1889-90. Also: Wien.
Med. Bl., 13: 22; 38, 1890.
69. Further observations on the cyanide of zinc and mercury.
Lancet, 1: 2-4, 1890. Also, abstr.: Tr. Hunter. Soc.
Lond., pp. 91-94, 1889-90.
70. On the present position of antiseptic surgery. In: Wood’s
M. & S. Monographs. N. Y. 8: 551-562, 1890. Also:
Vcrhandl. d. X. internat. rued. Cong., 1890, Berl., 1:
28-35, 1 891 . Also: Brit. M. J. 2: 377-379, 1890.
71. Lectures on Koch’s treatment of tuberculosis. Lancet,
2: 1257, 1890. Also: Brit. M. J., 2: 1372-1374, 1890.
72. On the principles of antiseptic surgery. Internat. Beitr. z.
wisscnsch. Med. Fcstschr. R. Virchow - — — , Berl., 3:
259-270, 1891.
73. On the coagulation of the blood in its practical aspects.
Brit. M. J., 1: 1057-1060, 1891. Also: Med. Press. &
Circ., n. s. 51: 449, 1891. Also: Lancet, 1: 10S1-1084,
1891. Also: Wien. Med. Bl., 14: 383; 398, 1891.
74. An address on the antiseptic management of wounds. Brit.
M. J., 1: 161-162; 277-2785337-339, 1893. Also: Lancet,
1: 179-180; 285-286; 345-347, 1893. Also, in Italian:
Gazz. mcd. lomb., Milano, 52: 165; 263; 288; 297, 309;
3 ^ 4 ; 334; 348, 1893.
75. Presidential address on the relation of clinical medicine to
modern scientific development. Brit. M. J., 2: 733-741,
1896.
76. Address as president before British Association for Advance-
ment of Science. Science, n. s. 4: 409-429, 1896.
77. L’art de guerir et la science. Rev. scient., Par., 4 s., 6:
481-494, 1896.
Joseph Lister 15
78. An address on the value of pathological research. Brit.
M. J., i: 317-319, 1897. Also: Rev. scient., Par., 4 s.
7: 208-211, 1897.
79. Lord Lister on the vaccination question. Abstr.: Lancet,
2: 426-427, 1898.
80. ‘The Huxley lecture; delivered to the Charing Cross Medical
School, Oct. 2, 1900. Brit. M. J., 2: 969-977, 1900.
81. On recent researches with regard to the parasitology of
malaria. Ibid., 2: 1625-1627, 1900. Also: Wien. med.
Presse, 42: 729-736, 1901.
82. On early researches leading up to the antiseptic system of
surgery. Lancet, 2: 985-993, 1900.
83. The third Huxley lecture; delivered before the Medical
School of Charing Cross Hospital. Lond., Harrison &
Sons, 58 pp., 8°, 1907.
84. Introduction to Stephen Paget’s “Experiments on Animals.”
N. Y., Wood, 1907.
85. Note on the preparation of catgut for surgical purposes.
Brit. M. J., 1: 125-126, 1908. Also: Lancet, 1: 148-149,
1908.
86. Remarks on the treatment of fractures of the patella of
long standing. Brit. M. J., 1: 849-850, 1908. Also:
Lancet, 1: 1049-1050, 1908.
87. Remarks on some points in the history of antiseptic surgery.
Brit. M. J., 1: 1557-1558, 1908. Also: Lancet, 1: 1815-
1816, 1908.
88 . On sulpho-chromic catgut. Lancet, I: 273, 1909.
89. The collected papers of Joseph, Baron Lister. 2 vol., 4 0 ,
Oxford, Clarendon Press, xliv, 429 pp., 14 pi., vii, 489 pp.,
4°, 1909. . j
90. Six papers by Lord Lister with a short biography and ex-
planatory notes by Sir Rickman J. Godlee. vii, 194 pp.*
Lond., J. Bale, 1921.
BIBLIOGRAPHY OF BIOGRAPHIES
Biography. Med. mod., Par., 7, suppl. 57, 1896.
Biography. Nature, Lond., 54: 1 -5* 1896.
Biography. Canad. Pract., Toronto, 22: 625-641, 1897.
Medical Classics
16
Biography. Pop. Sc. Month., N. Y., 52: 693-698, 1897-8.
Lord Lister and his pupils. Brit. M. J., I: 1374, 1897.
Lord Lister and his work. By G. T. McKcough. Physician &
Surg., Detroit, 20: 63-67, 1898.
Lord Lister and his work. By A. Miles. Edinb. Health Soc.,
Health Lect., 15: 99-112, 1898-99.
Lord Lister and the development of antiseptic surgery. By J.
Finlayson. Janus, 5: 1: 57, 1900.
Biography. N. Y. Med. J., 75: 1146, 1902.
List of Lord Lister’s contributions to medical and scientific
literature down to the year 1897. By Chiene. Brit. M. J.,
2: 1853, 1902.
Lister jubilee number. Brit. M. J., 2: 1817-1861, 1902.
Lister — jubilee, December 1902. By J. Berg. Hygiea, Stock-
holm, 2.f., 3: 282, I903.
Biography. By G. Hubert. Tidskr. f. d. norskc I.aegefor.,
Kristiania, 23: 347 ~ 359 > 1 9 ° 3 -
A trip to England and some reminiscences of Lord Lister. By
L. L. Hill. Mobile M. & S. J., 3: 487-494, 1903.
Biography. By W. Thulstrup. Tidsskr. f. Jordemj<dre, Kd-
benk., 17: 101-109, 1906-7.
Biography. By A. Martin & A. Rosthorn. Monntschr. f.
Geburtsh. u. Gynak., 25: 689-691, 1907.
Biography. By J.P. zum Busch. Munchcn. mcd. Wochenschr.,
54: 673-675, 1907.
Lord Lister and the antiseptic method. Editorial. Lancet,
I: 1617-1620, 1909.
Address on the presentation of a memorial of Lord Lister at the
opening of the new Glasgow Royal Infirmary, June 23,
1909. By R. J. Godlcc. Glasgow M. J., 72: 81-88, 1909.
Lister prize essay; the life and work of Lister. By C. C. \Y.
Judd. Johns Hopkins Hosp. Bull., 21: 293-304, 1910.
Lister and his work. By C. M. Steele. Plexus, Chicago, 16:
449-466, 1910.
Some personal reminiscences of Lord Lister. By L. L. Hill.
Med. Rcc., N. Y., 80: 327-329, 1911. Also: Tr. M. Ass.
Alabama, pp. 316-322, 1911.
Joseph Lister iy
Lister; his life and work. By A. A. Lendon. Australas. M.
Gaz., 31: 261-264, I 9 I 2.
Lord Lister. By N. A. Powell. Canada Lancet, 45: 655,
1911-12.
Lister; an appreciation. By R. Roxburgh. Bristol M. Chir. J.
30: 1-10, 1912.
Obituary. J. A. M. A., 58: 4 99, 1912.
Obituary. N. Y. Med. J., 95: 342, 1912.
Obituary. Brit. M. J., i: 397-402, 1912.
Obituary. Edinb. M. J., n.s. 8: 254-256, 1912,
Obituary. Lancet, 1: 465-472, 1912.
Obituary. Med. Press & Circ., n.s. 93: 117, 1912.
Obituary. Am. Med., n.s. 7: 74-76, 1912.
Obituary. Deutsche med. Wochenschr., 38, 1912.
Obituary. Bio.-chem. Bull., N. Y., 1: 371, 1911-1912.
Obituary. Glasgow M. J., 77: 190-196, 1912.
Obituary. Med. Times, 40: 68, 1912.
Biography. By E. Sonnenburg. Berl. klin. Wochenschr., 49:
485-487, 1912.
Funeral. Brit. M. J., i: 440-446, 1912.
Biography. By J. Stewart. Canad. J. M. & S., 31: 323-330,
1912.
Biography. By F. Trendelenburg. Deutsche med. Wochen-
schr., 38: 713-716, 1912.
Biography. By E. Payr. Deutsche Zeitschr. f. Chir., 120: 1-6,
1912.
Biography. By Hj. von Bonsdorff. Finska lak-sallsk. Landl.,
Helsingfors, 1 :343“347> J 9 12 -
Biography. B. J. Berg. Hygiea, Stockholm, 74: 257-264,
1912.
Biography. By A. DePage. J. med. de Brux., 17* 77 j i 9 12 *
Biography. By J. Lucas-Championniere. J. de med. et chir.
prat., Par., 83: 129-135, 1912.
Lord Lister and the era of modern surgery. By \\ . rl. oewara.
Albany M. Ann., 33: 449-451, 1912.
Lister in London. By J. Stewart. Canada Lancet, 45: 661-664,
1911-12.
1 8 Medical Classics
Personal recollections of Lord Lister. By J. Stewart. Canad.
Pract. & Rev., 37: 270-277, 1912.
Lord Lister; a tribute and an impression. By J. L. Waters.
Caledon. lM. J., Glasg., 9: 59-65, 1 91 2-13.
Memorial address in appreciation of Baron Joseph Lister. By
H. G. We then'll & W. W. Grant. Colorado Med., 9: 106--
110, 1912.
Biography. By A. Martin. Monatschr. f. Geburtsch. u.
Gyna'k., 35: 265-267, 1912.
Biography. By W. W. Chcync. Nature, Lond., 88: 556-560,
1912.
Biography. By O. Lanz. Ncdcrl. Tijdschr. v. Genccsk., 1 :
425-428, 1912.
Biography. By J.-L. Faurc. Presse med., 20: annexe, 185-187,
1912.
Biography. By H. Cacncn. Zeirschr. f. d. arztl. Forthild.,
Jena, 9: 161-164, 1912.
Personal reminiscences of Joseph Lister. By Sr. G. Baldwin.
Canad. J. M. & S., 3 1 : 343-347, 1912. Also: Canada Lancet,
45:672-674,1911-12.
Joseph Lister und seine Bedeutung fur die Chirurgie. By K.
Bautner. Deutsche med. Presse, 16: 53, 1912.
Surgical practice and its daily debt to Lister. By G. A. Bing-
ham. Canad. J. M. N S., 31 : 348-350, 1912. Also, abstr.:
Canada Lancet, 45: 668, 1911-12.
Biography. By Sir W. Maccwen. Proc. Roy. Inst. Gr. Brit.,
20: pt. 2: 546-564, 1912.
Biography. By J. Lucas-Championniere. Rev. do. chir., Par.,
45: 5 2 9“543, i9«- c ,
Biography. By J. Akermann. I idsskr. i mil. Halsov., Stock-
holm, 37: 83-90, 1912.
Biography. By V. Meisen. Ugesk. f. I.acger, Kj^benh., 74:
284-293, 1912.
Biography. By F. C. Pybus. Univ. Durham Coll. Med. Gaz.,
Newcastle, 13: 157-159, 1912-13.
Biography. By F. H. Hancock. Virginia M. Semi-Month.,
Richmond, 17: 15-20, 1912-13.
Joseph Lister ip
Biography. By A. Fraenkel. Wien. klin. Wochenschr., 25:
381-386, 1912.
Biography. By Moszkowicz. Wien. med. Wochenschr., 62:
509, 1912.
Lister and the catgut ligature. By H. C. Cameron. Brit. M. J.
1:579, 1912.
A memory and an appreciation of Lister. By H. C. Cameron.
Canad. J. M. & S., 31 : 288-295, 1912. Also, abstr.: Canada
Lancet, 45: 664-668, 1911-12.
The influence of the researches of Pasteur and Lister on surgical
pathology. By H. C. Cameron. Canad. J. M. & S., 31:
3 1 1-322, 1912.
Lister’s work and teaching. By Sir W. W. Cheyne. Clin. J.
Lond., 41: 257-266, 1912-13. Also: Tr. M. Soc., Lond.,
36: 1-19, 1 91 2-13.
Lister, an appreciation. By J. B. Huber. Am. Pract., N. Y.,
• 46: 116-122, 1912.
Personliche Erinneurungen an Joseph Lister. By Madelung.
Strassb. med. Zeitg., 9: 55-60, 1912.
Lister in Glasgow. By A. E. Malloch. Canada Lancet, 45:
656-658, 1911-12.
Some memories of Mr. Lister. By A. E. Malloch. Canad. J.
M. & S., 31: 331-336, 1912.
Personal reminiscences of Lister. By A. E. Malloch. Canad.
M. Ass. J., i: 502-506, 1912.
Joseph Lister in seiner Bedeutung fur das Rettungswesen. By
O. Marcus. Zeitschr. f. Samariter-u. Rettungsw., Leipz.,
18: 41, 1912.
Personal reminiscences of Lord Lister. By H. A. Marcy.
Canada Lancet, 45: 669-671, 1911-12.
Personal reminiscences of Lord Lister; the introduction and
development of antiseptic surgery in America. By H. A.
Marcy. Am. J. Surg., 26: 97-101, 1912.
Reminiscences of the late Lord Lister. By R. H. Marten &
W. T. Hayward. Australas. M. Gaz., 31: 293-297, 1912.
The funeral of Lord Lister. By Sir W. Osier. Canad. M. Ass.
J-> 343> J9 12 -
1 8 Medical Classics
Personal recollections of Lord Lister. By J. Stewart. Canad.
Pract. & Rev., 37: 270-277, 1912.
Lord Lister; a tribute and an impression. By J. L. Waters.
Caledon. M. J., Glasg., 9: 59-65, 1 91 2-1 3.
Memorial address in appreciation of Baron Joseph Lister. By
H. G. Wetherill & W. W. Grant. Colorado Med., 9: 106-
110, 1912.
Biography. By A. Martin. Monatschr. f. Geburtsch. u.
Gynak., 35: 265-267, 1912.
Biography. By W. W. Cheyne. Nature, Lond., 88: 556-560,
1912.
Biography. By O. Lanz. Nederl. Tijdschr. v. Gcncesk., 1 :
425-428, 1912.
Biography. By J.-L. Faure. Presse med., 20: annexe, 185-187,
1912.
Biography. By H. Caenen. Zeitschr. f. d. arztl. Forthild.,
Jena, 9: 161-164, !9 12 -
Personal reminiscences of Joseph Lister. By St. G. Baldwin.
Canad. J. M. & S., 31 : 343-347, 1912. Also: Canada Lancet,
45: 672-674, 1911-12.
Joseph Lister und seine Bedeutung fur die Chirurgie. By E.
Baumer. Deutsche med. Presse, 16: 53, 1912.
Surgical practice and its daily debt to Lister. By G. A. Bing-
ham. Canad. J. M. & S., 31 : 348-350, 1912. Also, abstr.:
Canada Lancet, 45: 668, 1911-12.
Biography. By Sir W. Macewen. Proc. Roy. Inst. Gr. Brit.,
20: pt. 2: 546-564, 1912.
Biography. By J. Lucas-Championniere. Rev. de. chir., Par.,
45: 529-543, 1912.
Biography. By J. Akermann. Tidsskr. i mil. Halsov., Stock-
holm, 37: 83-90, 1912.
Biography. By V. Meisen. Ugesk. f. Laeger, Kj^benh., 74:
28 4" 2 93> I 9 12 *
Biography. By F. C. Pybus. Univ. Durham Coll. Med. Gaz.,
Newcastle, 13: 157— 1 59, 1912-13.
Biography. By F. H. Hancock. Virginia M. Semi-Month.,
Richmond, 17: 15-20, 1912-13.
Joseph Lister 19
Biography. By A. Fraenkel. Wien. Idin. Wochenschr., 25:
381-386, 1912.
Biography. By Moszkowicz. Wien. med. Wochenschr., 62:
509, 1912.
Lister and the catgut ligature. By H. C. Cameron. Brit. M. J.
1:579, 1912.
A memory and an appreciation of Lister. By H. C. Cameron.
Canad. J. M. & S., 31 : 288-295, 1912. Also, abstr.: Canada
Lancet, 45: 664-668, 1911-12.
The influence of the researches of Pasteur and Lister on surgical
pathology. By H. C. Cameron. Canad. J. M. & S., 31:
31 1-322, 1912.
Lister’s work and teaching. By Sir W. W. Cheyne. Clin. J.
Lond., 41: 257-2 66, 1912-13. Also: Tr. M. Soc., Lond.,
36: 1-19, 1912-13.
Lister, an appreciation. By J. B. Huber. Am. Pract., N. Y.,
46: 116-122, 1912.
Personliche Erinneurungen an Joseph Lister. By Madelung.
Strassb. med. Zeitg., 9: 55-60, 1912.
Lister in Glasgow. By A. E. Malloch. Canada Lancet, 45:
656-658, 1911-12.
Some memories of Mr. Lister. By A. E. Malloch. Canad. J.
M. & S., 31: 331-336, 1912.
Personal reminiscences of Lister. By A. E. Malloch. Canad.
M. Ass. J., 2: 502-506, 1912.
Joseph Lister in seiner Bedeutung fur das Rettungswesen. By
O. Marcus. Zeitschr. f. Samariter-u. Rettungsw., Leipz.,
18: 41, 1912.
Personal reminiscences of Lord Lister. By H. A. Marcy.
Canada Lancet, 45: 669-671, 1911-12.
Personal reminiscences of Lord Lister; the introduction and
development of antiseptic surgery in America. By H. A.
Marcy. Am. J. Surg., 26: 97-roi, 1912.
Reminiscences of the late Lord Lister. By R. H. Marten &
W. T. Hayward. Australas. M. Gaz., 31: 293-297, 1912.
The funeral of Lord Lister. By Sir W. Osier. Canad. M. Ass.
J-> 2: 343, 1912.
20 Medical Classics
A reminiscence of Lister. By L. S. Pilcher. Long Island M. J.,
pp. 122-124, 1912.
Lister and his relation to the discovery of the antiseptic principle
of the treatment of wounds. By B. Foster. St. Paul M. J.,
14: 601-610, 1912.
Personal recollections of Lord Lister. By F. LeM. Grasett.
Canad. J. M. & S., 31 : 296-310, 1912.
Lister in Edinburgh. By F. LeM. Grasett. Canada Lancet, 45:
658-661, 1911-12.
Personal recollections of Lord Lister. By F. LeM. Grasett.
Dominion M. Month., 38: 181-194, 1912.
Lister, man of science, surgeon, teacher. By D. B. Hart. Univ.
M. Rec. Lond., 1: 193-201, 1912.
Lord Lister; his life and work. By G. T. Wrench. 383 pp., 8°,
London, T. F. Unwin, 1913.
Biography. By E. Burci. Atti d. Accad. med. fis. fiorent.,
1912, Firenze, pp. 19-24, 1913.
Biography. By W. W. C. Proc. Roy. Soc. Lond., 86: s.B.,
pp. i-xxi, 1913.
Biography. By F. H. Gerrish. Tr. Am. Surg. Ass., 21 : pp.
xxxi-xxxiv, 1913.
Lister. By S. Paget. Cornhill Mag., 35: 604-611, 1913.
Lister, the laboratory and the bedside. By R. H. Russell.
Austral. M. J., 3: 1437-1444, 1913-14. Also: Brit. M. J.,
i: 745-748, 1914. Also: N. Zealand M. J., 13: 115-131,
I 9 I 4-
Lister and antiseptic surgery. By Sir R. J. Godlee. Surg.
Clin., Chicago, 3: 91-95, 1914.
Tribute to Lister. By Lucas-Championniere. Tr. Internat.
Cong. Med., 1913, Lond., 1914, Sect. 7, Surg., p. 2, 5.
Lord Lister. By Sir W. Macewen. Proc. Roy. Inst. Gr. Brit.,
1911-13, Lond., 20: pt. 2, 546-564, 1914.
An address on “Lord Lister.” By Sir H. Allen. Med. J.
Australia, i: 25-27, 1914.
Personal reminiscences of Lister. By H. A. Marcy. Med.
Pickwick, Saranac Lake, p. 235-237, 1915.
Biography. By T. L. Cramhall. Univ. Durham Coll. Med.
Gaz., 17: 45; 62, 1916-17.
Joseph Lister 21
Lord Lister. By Sir R. J. Godlee. 8°, London, 1917. 2 ed.,
1918. 3 ed., 1924.
Biography. Hospital, Lond., 63: 351; 371; 393; 415, 1917-18.
Lister on the use of animals in research. By W. M. Keen.
J. Am. M. Ass., 68: 53, 1917.
What Lister did. By J. Haddon. Med. Press, Lond., n.s. 105:
227, 1918.
An appreciation of Sir John Rickman Godlee’s life of Lord Lister.
By J. Stewart. Canad. M. Ass. J., 8: 753-757, 1918.
A house-surgeon’s memories of Joseph Lister. By Sir St. C.
Thomson. Ann. Med. Hist., 2: 93-108, 1919. Also:
Mod. Hosp.,- 13: 1, 1919.
Unveiling of Lister memorial tablets. Nature, London, 104:
3 22 > I 9 I 9 *
Biography. By F. R. Packard. Ann. Med. Hist., 2: 208, 1919.
The coming of Lister to London. By Sir St. C. Thomson. St.
Barth. Hosp. J., 28: 54; 67, 1920-21.
Lister, his life and work. By P. F. Clark. Scient. Monthly,
II; 518-5393 I 9 2 °-
Reminiscences of Lister and war work. By A. Corless. Canad.
Pract. & Rev., 45: 411, 1920; 46: 1, 1921.
Presentation of memento of Lord Lister for the custodianship
case. By R. Abbe. Tr. Coll. Phys., Phila., 3.S., 43: 146-
148, 1921.
Lord Lister, the discoverer of the antiseptic system of surgery.
By E. Cohen. Discovery, Lond., 2: 22-24, 1921.
Biography. By H. L. Staples. Journal-Lancet, 42: 439-444,
Sept. 1, 1922.
Lord Lister and his priceless gift to man. By J. A. Hunnicutt,
Jr., J. M. A. Georgia, 1 1 : 473 “ 475 > I 9 22 -
Lord Lister. By Cuthbert Dukes. 12 0 , Lond., L. Parsons;
Boston, Small, Maynard & Co., 1924.
Biography. By J. H. Barclay. Univ. Durham Coll. Med. Gaz.,
2 5 : 2 5 ~ 3 5 > i 9 2 4 _2 5 - . . . , .
Centenary of founders of modern scientific medicine and surgery,
Pasteur and Lister. By H. G. W’etherill. Colorado bled.,
21: 29-33, 1924.
Biography. M. J. & Record, 120: 444-447? : 9 2 4-
22 Medical Classics
Biography. By H. C. Cameron. Glasgow M. J., 102: 209-214,
1924.
Surgical reminiscence of Lister. By J. Patrick. Ibid., 101 :
I4S-150, 1924.
Glasgow memorial to Lord Lister. Lancet, 2: 625, 1924.
Lister and his achievement; being the first Lister memorial
lecture delivered at the Royal College of Surgeons of Eng-
land on May 14, 1925 by Sir William Watson Cheyne.
Lancet, 1: 1011-1018, 1925. Also: Brit. M. J., i: 923-926,
1925. Also: 8°, London & N. Y., Longmans, Green & Co.,
1 9 2 5 -
The place of Lord Lister in the field of surgery. By G. W. Mid-
dleton. Am. Med., n.s. 20: 54 4 ~ 55 2 > 1 9 2 5 *
Lister and the ligature; a landmark in the history of modern
surgery. New Brunswick, N. Y., Johnson & Johnson,
1925.
Personal recollections. By W. W. Keen. Surg., Gynec. &
Obst., 45: 861-864, 1927.
Presentation of Lister memorial tablet. By H. G. Wetherill.
Ibid., 45: 858-860, 1927.
Presentation of replicas of Lister exhibition. By H. S. Well-
come. Ibid., 45: 856-858, 1927.
Recent books about Lister; centenary contribution. By R. S.
Skirving. M. J. Australia, 2: 87-90, 1927.
Recollections of Lister by J. P. zum Busch. Deutsche med.
Wochenschr., 53: 583-585, 1927.
Lister letter and case report: case of ascites due to cirrhosis of
liver cured by operation. By R. Morison & D. Drummond.
Newcastle M. J., 7: 247, 1927.
Lister or Bottini? By A. Clerici. Illust. med. ital., 9: 961,
1 ?* 7 -
Listeriana. Irish J. M. Sc., pp. 557-560, 1927.
Listerism in Germany. By M. von Gruber. Munchen. med.
Wochenschr., 74: 592, 1927.
Lord Lister and the renaissance of surgery. By E. L. Gilcrest.
S. Clin. North America, 7: 1117-1123, 1927.
Lord Lister’s life and work. By A. Young. Janus, 31 : 318-335,
1927.
Joseph Lister 23
Historical sketch. By C. F. Painter. Boston M. & S. J.,
196: 1093-1096, 1927.
Lister’s influence on modern surgery. By G. M. Ohmart. J.
Michigan M. Soc., 26: 679-681, 1927.
Letter of Lord Lister. Deutsche med. Wochenschr., 53: 585,
I 9 2J.
Lister and malaria. Science Prog., 22: 114-116, 1927.
Lister and West London Medico-Chirurgical Society. By F. J.
McCann. West London M. J., 32: 148-152, 1927.
Lister and physiology. By C. S. Sherrington. Nature, London,
1 19: 606-608, 1927.
Lister celebrations in London. Ibid., 119: 570-572, 1927.
Methods in surgery. By W. W. Cheyne. Ibid., 120: 161, 1927.
Lister’s contribution to preventive medicine. By C. J. Martin.
Ibid., 1 19: 529-531, 1927.
Lister’s scientific work. By W. Bullock. Ibid., 119: 531-533,
^27.
What Lord Lister’s work has meant to surgery. By R. J. Reed.
W. Virginia M. J., 23: 330-332, 1927.
Centenary of Lister; tale of sepsis and antisepsis. By A. P. C.
Ashhurst. Ann. M. Hist., 9: 205-221, 1927.
Comparative contributions of Lister and Osier. By W. B.
Munro. California & West. Med., 27: 44-47) J 9 2 7-
(Lister). Emancipators. By H. Cushing. Lancet, 2: 185-186,
1927. Also: Boston M. & S. J., 197: 651-652, 1927.
Biography. By C. Kaufmann. Schweiz, med. Wochenschr.,
57: 313-315. J 9 2 7*
Biography. By V. Schaldemose. Ugesk. f. Laeger, 89: 267-
273, 1927.
Biography. By V. Schmieden. Klin. Wochenschr., 6: 721,
I 9 2J.
Biography. By J. A. Spalding. J. Maine M. A., 18: 149-153,
J 9 2J.
Biography. By G. Turner. Vrach. Gaz., 31: 643-646, 1927.
Biography. By A. Vedrani. Illust. med. ital., 9: 87-96, 1927.
Address on approach to surgery. By B. Moynihan. Brit. M.
J., 2: 621-624, 1927.
Medical Classics
24
Appreciation of Lord Lister. By J. Bland-Sutton. Surg.,
Gynec. & Obst., 45: 867-868, 1927 -
Lister as physiologist. By J. Tait. Science, 66: 267-0.72, 1927.
Biography. Presse med., 35: 523, 1927.
Biography. By W. Boyd. Journal-Lancet, 47: 557-564, 1927.
Biography. By D. Cheever. Boston M. & S. J., 196: 984-993,
1927.
Biography. By A. Eiselberg. Wien. klin. Wochenschr., 40:
461-465, 1327.
Biography. By J. L. Gibson. M. J. Australia, 1 : 844-850,
1927.
Biography. By C. E. Goddard. Ibid., i: 850-856, 1927.
Biography. By H. von Haberer. Deutsche med. Wochenschr.,
53:582,1927.
Biography. By H. L. Harley. J. M. Soc. New Jersey, 24:
557-56 1 , 1927.
Biography. By N. B. Harman. West London M. J., 32:
57-60, 1927.
Biography. By H. Hartmann. Bull. Acad, de med., Paris,
97: 469-47 3, 1927. Also: Gaz. d. hop., 100: 509, 1927.
Biography. By L. L. Hill. Am. J. Surg., 3: 99-110, 1927.
Lister centenary celebrations in London. M. J. & Rec., 125:
706, 768, 1927.
Lister; house-surgeon’s memories. By S. Thomson. Brit.
M. J., 1: 659-662, 1927. Also: Lancet, i: 775-780, 1927.
Abridged in: M. J. & Rec., 125: 772-773, 1927.
Lord Lister as pathologist and bacteriologist. By W. Bullock.
Brit. M. J., i: 654-656, 1927. Also: Lancet, 1: 744-746,
19 2 7 ;
Recollections of Lister. By C. E. Wallis. J. Am. Dent. A.,
14: 707-713, 1927.
Hunter’s ideal and Lister’s practice. By B. Moynihan. Brit.
M. J. 1: 313-319, 1927. Abridged in: Lancet, i: 373 ~ 379 >
1927.
Lister as a physiologist. By C. S. Sherrington. Brit. M. J.,
i: 653-654, 1927. Also: Lancet, 1: 743-744, 1927.
Lister as a surgeon. By B. Moynihan. Brit. M. J., i: 656-
658, 1927. Also: Lancet, 1: 746-748, 1927.
2 5
Joseph Lister
Lister centenary. By E. Chapman. Hygeia, 5: 193, 1927.
Lister centenary celebrations. Glasgow M. J., 107: 265-189,
I 9 2 7 ‘
The conquest of sepsis. By Sir J. Bland-Sutton. Lancet, 1:
781-786, 1927.
Biography. By N. B. Harman. Canad. M. A. J., 17: 589—
590, 1927.
Biography. By E. St. Jacques. Ibid., 658-661, 1927.
Case of excision of knee and elbow joints by Lord Lister; condi-
tion 40 years later. By G. T. Beatson. Brit. M. J., 1:
662-663, 1927.
Domestic survey. By H. Rolleston. Lancet, i: 780-781, 1927.
Remembrances of Lord Lister. By R. Morison. Newcastle
M. J., 7: 242-246, 1927.
Reminiscences of 50 years ago. By F. R. Cross. Bristol Med.-
Chir. J., 44: 112A-112D, 1927.
Lister and modern surgery. By H. W. Orr. Nebraska M. J.,
12: 411-416, 1927.
Surgical instruments designed by Lister. By C. J. S. Thompson.
Boston M. & S. J., 196: 946-951, 1927.
Centenary; tale of sepsis and antisepsis. By A. P. C. Ashhurst.
Tr. Coll. Physicians, 49: 70-93, 1927.
The man and his achievements. By E. L. Gilcrest. Tr. South.
S. A., 40: 166-174, 1927.
Lister centenary volume. Edited by J. L. Turner. Edinburgh,
Oliver & Boyd, 1927.
Lister as I knew him. By J. R. Leeson. N. Y., Wood, 1927.
My reminiscences of Lord Lister in Edinburgh. By F. L.
Grasett. Pub. Health J., 19: ii5 _ h8, 1928.
Personal recollections. By W. W. Keen. Hygiea, 90: 66-75,
1928.
Personal reminiscences. By E. St. G. Baldwin. Pub. Health
J., 19: 112-114, 1928.
Biography. By F. K. Boland. South. M. J., 21: 33 ~ 35 >
Anecdote of Lord Lister. By J. Riddell. M. J. & Rec., 126:
747, 1927.
Lister as scientist. By J. J. R- Macleod. Pub. Health J.,
19: 101-in, 1928.
26 Medical Classics
Lister as scientist. By G. E. Seaman. Wisconsin M. J.,
27 : 5 1 ; 99> J 9 i8 -
Lister’s influence on modern surgery. By H. C. Mack. J.
Michigan M. Soc., 27: 33- 41, 1928.
Life of Lister. By E. J. Horgan. Virginia M. Monthly, 54:
607-612, 1928.
A paper that inaugurated a new surgical era. (New method of
treating compound fracture, abscess, etc.) By T. S. W.
Am. J. Surg., 7: 287-289, 1929.
Letters. (Briefe aus vergangenen Tagen.) Deutsche med.
Wochenschr., 56: 24, 1930.
Semmelweis and Lister. By B. A. G. Veraart. Nederl. tijdschr.
v. geneesk., 74: 1762-1775, 1930.
Biography. By E. P. Quain. Minnesota Med., 13: 445-450,
1930 -
Lister — the idealist; Listerian oration. By Moynihan. Brit.
M. J. (Canad. suppl.) pp. 7-12, 1930, Also: Canad. M.
A. J., 23: 479-488, 1930.
Biography. By J. Alvarez Sierra. Dia med., 3: 521, 1931.
Lister’s early bacteriological researches and origin of his anti-
septic system; Listerian oration. By C. Martin. M. J.
Australia, 2: 437-444, 1931.
Lister; pioneer of medicine. By C. Lillingston. Hygeia, 10:
144-147, 1932.
House-surgeon’s memories of Lister. By St. C. Thomson.
Birmingham M. Rev., 7: 300-311, 1932.
A student under Lister; Anne Mackenzie oration. By R. H.
Russell. M. J. Australia, 1: 669-674, 1932.
Eight letters of Lister to William Sharpey. By C. R. Rudolf.
Brit. J. Surg., 20: 145-164, 1932; 20: 459-466, 1933.
Agostino Bassi, early parasitologist (work of Bassi, Lister and
Semmelweis and review of development of conception of
contagion). By L. Munster. Janus, 37: 221-246, 1933.
Lister and his time. By C. Ballance. Lancet, 1: 815-816,
I9 33-
Lister and wiring patella; ipsissima verba. By D’A. Power.
Brit. J. Surg., 21: 557-559, 1934.
Joseph Lister 27
Lister’s role in progress of surgery. By R. Munoz Carbonero.
Cr6n. med.j Valencia, 38: 158-160, 1934.
Lister as physiologist; Listerian oration. By W. A. Osborne.
M. J. Australia, i: 761-765, 1935.
Life, work and character; Listerian oration. By H. Newland.
M. J. Australia, i: 263-270, 1935.
Great physician, who founded the science of modern surgery.
By A. Berlin. Hygeia, 13: 643, 1935.
Lister’s mind and character. By E. Archibald. Canad. M.
A. J-, 35 '• 475 - 49 °. J 93 6 -
On a New Method of Treating
Compound Fracture, Abscess,
Etc., with Observations on the
Conditions of Suppuration
BY
JOSEPH LISTER, Esq., F.R.S.
Professor of Surgery in the University of Glasgow
Published in The Lancet, i: 316-3:9; 35^—359; 387-389; 507-509; :: 95-96, 1867
PART I. ON COMPOUND FRACTURE
HE frequency of disastrous consequences in com-
pound fracture, contrasted with the complete
immunity from danger to life or limb in simple
fracture, is one of the most striking as well as
melancholy facts in surgical practice.
If we inquire how it is that an external w r ound
communicating with the seat of fracture leads to such grave re-
sults, we cannot but conclude that it is by inducing, through
access of the atmosphere, decomposition of the blood which is
effused in greater or less amount around the fragments and among
the interstices of the tissues, and, losing by putrefaction its nat-
ural bland character, and assuming the properties of an acrid
irritant, occasions both local and general disturbance.
We know that blood kept exposed to the air at the tempera-
ture of the body, in a vessel of glass or other material chemically
inert, soon decomposes; and there is no reason to suppose that
Compound Fracture, Abscess 2 9
the living tissues surrounding a mass of extravasated blood
could preserve it from being affected in a similar manner by the
atmosphere. On the contrary, it may be ascertained as a matter
of observation that, in a compound fracture, twenty-four hours
after the accident the coloured serum which oozes from the
wound is already distinctly tainted with the odour of decompo-
sition, and during the next two or three days, before suppura-
tion has set in, the smell of the effused fluids becomes more and
more offensive.
This state of things is enough to account for all the bad con-
sequences of the injury.
The pernicious influence of decomposing animal matter upon
the tissues has probably been underrated, in consequences of
the healthy state in which granulating sores remain in spite of a
very offensive condition of their discharges. To argue from this,
however, that fetid material would be innocuous in a recent
wound would be to make a great mistake. The granulations
being composed of an imperfect form of tissue, insensible and
indisposed (p. 327) to absorption, but with remarkably active
cell-development, and perpetually renovated as fast as it is de-
stroyed at the surface, form a most admirable protective layer,
or living plaster. But before a raw surface has granulated, an
acrid discharge acts with unrestrained effect upon it, exciting
the sensory nerves, and causing through them both local inflam-
mation and general fever, and also producing by its caustic
action a greater or less extent of sloughs, which must be thrown
off by a corresponding suppuration, while there is at the same
time a risk of absorption of the poisonous fluids into the circu-
lation.
This view of the cause of the mischief in compound fracture
is strikingly corroborated by cases in which the external wound
is very small. Here, if the coagulum at the orifice is allowed to
dry and form a crust, as was advised by John Hunter,* all bad
consequences are probably averted, and, the air being excluded,
the blood beneath becomes organised and absorbed, exactly as
* See Works of J. Hunter, edited by Palmer, vol. L, p. 429.
30 Medical Classics
in a simple fracture. But if any accidental circumstance inter-
feres with the satisfactory formation of the scab, the small-
ness of the wound, instead of being an advantage, is apt to prove
injurious, because, while decomposition is permitted, the due
escape of foul discharges is prevented. Indeed, so impressed
are some surgeons with the evil which may result from this
latter cause, that, deviating from the excellent Hunterian prac-
tice, they enlarge the orifice with the knife in the first instance
and apply fomentations, in order to mitigate the suppuration
which they render inevitable.
Turning now to the question how the atmosphere produces
decomposition of organic substances, we find that a flood of
light has been thrown upon this most important subject by the
philosophic researches of M. Pasteur, who has demonstrated by
thoroughly convincing evidence that it is not to its oxygen or
to any of its gaseous constituents that the air owes this prop-
erty, but to minute particles suspended in it, which are the
germs of various low forms of life, long since revealed by the
microscope, and regarded as merely accidental concomitants of
putrescence, but now shown by Pasteur to be its essential cause,
resolving the complex organic compounds into substances of
simpler chemical constitution, just as the yeast-plant converts
sugar into alcohol and carbonic acid.
A beautiful illustration of this doctrine seems to me to be
presented in surgery by pneumothorax with emphysema, result-
ing from puncture of the lung by a fractured rib. Here, though
atmospheric air is perpetually introduced into the pleura in great
abundance, no inflammatory disturbance supervenes; whereas
an external wound penetrating the chest, if it remains open,
infallibly causes dangerous suppurative pleurisy. In the latter
case the blood and serum poured out into the pleural cavity,
as an immediate consequence of the injury, are decomposed by
the germs that enter with the air, and then operate as a powerful
irritant upon the serous membrance. But in case of puncture of
the lung without external wound, the atmospheric gases are
filtered of the causes of decomposition before they enter the
pleura, by passing through the bronchial tubes, which, by their
small size, their tortuous course, their mucous secretion, and cili-
Compound Fracture, Abscess 31
ated epithelial lining, seem to be specially designed to arrest all
solid particles in the air inhaled. Consequently the effused
fluids retain their original characters unimpaired, and are
speedily absorbed by the unirritated pleura.
Applying these principles to the treatment of compound frac-
ture, bearing in mind that it is from the vitality of the atmos-
pheric particles that all the mischief arises, it appears that all
that is requisite is to dress the wound with some material cap-
able of killing these septic germs, provided that any substance
can be found reliable for this purpose, yet not too potent as a
caustic.
In the course of the year 1864 I was' much struck with an
account of the remarkable effects produced by carbolic acid upon
the sewage of the town of Carlisle, the admixture of a very small
proportion not only preventing all odour from the lands irri-
gated with the refuse material, but, as it was stated, destroying
the entozoa which usually infest cattle fed upon such pastures.
My attention having for several years been much directed to
the subject of suppuration, more especially in its relation to
decomposition, I saw that such a powerful antiseptic was pecu-
liarly adapted for experiments with a view to elucidating that
subject, and while I was engaged in the investigation the applica-
bility of carbolic acid for the treatment of compound fracture
naturally occurred to me.
My first attempt of this kind was made in the Glasgow Royal
Infirmary in March, 1865, in the case of compound fracture of
the leg. It proved unsuccessful, in consequence, as I now be-
lieve, of improper management; but subsequent trials have
more than realised my most sanguine anticipations.
Carbolic acid* proved in various ways well adapted for the
* Carbolic acid is found in the shops in two forms — the glacial or crystalline, solid at
ordinary temperatures of the atmosphere; and the fluid, which sometimes passes under the
name of German creasote. The fluid variety is sold in various degrees of purity. The
crude forms are objectionable from their offensive odour; but the properly rectified product
is almost fragrant. Different samples, however, differ much in energy of action, and
hence, though I have hitherto employed the liquid kind in compound fracture, it would
probably be better to use the crystallised form, melting it by placing the vessel containing
it in warm water for a few minutes. Carbolic acid is almost absolutely insoluble in water,
but dissolves readily in various organic liquids, such as the common fixed oils or glycerine.
Medical Classics
3 2
purpose. It exercises a local sedative influence upon the
sensory nerves; and hence is not only almost painless in its im-
mediate action on a raw surface, but speedily renders a wound
previously painful entirely free from uneasiness. When em-
ployed in compound fracture its caustic properties are mitigated
so as to be unobjectionable by admixture with the blood, with
which it forms a tenacious mass that hardens into a dense crust,
which long retains its antiseptic virtue, and has also other ad-
vantages, as will appear from the following cases, which I will
relate in the order of their occurrence, premising that, as the
treatment has been gradually improved, the earlier ones are not
to be taken as patterns.
Case i. — James G , aged eleven years, was admitted into
the Glasgow Royal Infirmary on August 12th, 1865, with com-
pound fracture of the left leg, caused by the wheel of an empty
cart passing over the limb a little below its middle. The wound,
which was about an inch and a half long, and three-quarters of
an inch broad, was close to, but not exactly over, the line of frac-
ture of the tibia. A probe, however, could be passed beneath
the integument over the seat of fracture and for some inches
beyond it. Very little blood had been extravasated into the
tissues.
My house-surgeon, Dr. Macfee, acting under my instructions,
laid a piece of lint dipped in liquid carbolic acid upon the wound,
and applied lateral pasteboard splints padded with cotton wool,
the limb resting on its outer side, with the knee bent. It was
left undisturbed for four days, when, the boy complaining of some
uneasiness, I removed the inner splint and examined the wound.
It showed no signs of suppuration, but the skin in its immediate
vicinity had a slight blush of redness. I now dressed the sore
with lint soaked with water having a small proportion of carbolic
acid diffused through it; and this was continued for five days,
during which the uneasiness and the redness of the skin disap-
peared, the sore meanwhile furnishing no pus, although some
superficial sloughs caused by the acid were separating. But the
epidermis being excoriated by this dressing, I substituted for it
a solution of one part of carbolic acid in from ten to twenty
Compound Fracture, Abscess 33
parts of olive oil., which was used for four days, during which a
small amount of imperfect pus was produced from the surface
of the sore, but not a drop appeared from beneath the skin. It
was now clear that there was no longer any danger of deep-seated
suppuration, and simple water-dressing was employed. Cicatri-
sation proceeded just as in an ordinary granulating sore. At
the expiration of six weeks I examined the condition of the
bones, and, finding them firmly united, discarded the splints;
and two days later the sore was entirely healed, so that the cure
could not be said to have been at all retarded by the circum-
stance of the fracture being compound.
This, no doubt, was a favourable case, and might have done
well under ordinary treatment. But the remarkable retardation
of suppuration, and the immediate conversion of the compound
fracture into a simple fracture with a superifical sore, were most
encouraging facts.
Case 2. — Patrick F , a healthy labourer, aged thirty-two,
had his right tibia broken on the afternoon of Sept, nth, 1865,
by a horse kicking him with its full force over the anterior
edge of the bone about its middle. He was at once taken to the
infirmary, where Mr. Miller, the house-surgeon in charge, found
a wound measuring about an inch by a quarter of an inch, from
which blood was welling profusely.
He put the fracture in pasteboard splints, leaving the wound
exposed before their anterior edges, and dressing it with a piece
of lint dipped in carbolic acid, large enough to overlap the sound
skin about a quarter of an inch in every direction. In the
evening he changed the lint for another piece, also dipped in
carbolic acid, and covered this with oiled paper.* I saw the
patient the next day, and advised the daily application of a bit
of lint soaked in carbolic acid over the oiled paper; and this
(p. 328) was done for the next five days. On the second day
there was an oozing of red fluid from beneath the dressing, but
by the third day this had ceased entirely. On the fourth day,
when, under ordinary circumstances, suppuration would have
* A cheap substitute for oiled silk, devised by the late Dr. M’Ghee, of the Glasgow
Infirmary, and very useful for covering poultices, &c.
Medical Classics
34
made its appearance, the skin had a nearly natural aspect, and
there was no increase of swelling, while the uneasiness he had
previously felt was almost entirely absent. His pulse was 64,
and his appetite improving. On the seventh day, though his
general condition was all that could be wished, he complained
again of some uneasiness, and the skin about the still adherent
crust of blood, carbolic acid and lint, was found to be vesicated,
apparently in consequence of the irritation of the carbolic acid.
From the seventh day the crust was left untouched till the
eleventh day, when I removed it, disclosing a concave surface
destitute of granulations, and free from suppuration. Water-
dressing was now applied, and by the sixteenth day the entire
sore, with the exception of one small spot where the bone was
bare, presented a healthy granulating aspect, the formation of
pus being limited to the surface of the granulations.
I now had occasion to leave Glasgow for some weeks, and did
so feeling that the cure was assured. On my return, however,
I was deeply mortified to learn that hospital gangrene attacked
the sore soon after I went away, and made such havoc that
amputation became necessary.
While I could not but feel that this case, by its unfortunate
issue, might lose much of its value in the minds of others, yet
to myself it was perfectly conclusive of the efficacy of carbolic
acid for the object in view. At the same time it suggested some
improvement in matters of detail. It showed that the acid
may give rise to a serous exudation apt to irritate by its accumu-
lation, and therefore that a warm and moist application would
be advantageous to soothe the part, and also ensure the free
exit of such exuded fluid. At the same time it appeared desir-
able to protect the crust with something that would retain the
volatile organic acid more effectually than oiled silk or gutta
percha, through which it makes its way with the utmost facility.
For this purpose a metallic covering naturally suggested itself,
and as ordinary tin-foil is unsuitable from its porosity, I em-
ployed thin sheet-lead, and afterwards block tin, such as is
used for covering the jars of anatomical preparations, superior
to lead on account of the facility with which it can be moulded
to any shape that is desired.
Compound Fracture, Abscess 35
For a long time, however, I had no opportunity of giving this
improvement a trial, the compound fractures admitted into my
wards during the next eight months being merely two cases with
small wounds. One of these was a fracture of the ulna into the
elbow-joint in a woman so old that suppuration, had it occurred,
would probably have proved fatal. The orifice in the integu-
ment was extremely small, and all would most likely have gone
on well had the bit of dry lint applied to check the free bleeding
from the interior been left undisturbed, instead of being satu-
rated with carbolic acid as it was. This, however, could not
but be an additional safeguard, and at the same time it was
satisfactory to find that the caustic application did not interfere
with the usual healing by scabbing, cicatrisation being found
complete when the crust was removed.
The other case was a fracture of the humerus a little above the
elbow in a young man, caused by a fall from a height of thirty-
five feet, the wound, which was not quite half an inch in length,
being situated at the inner side of the limb, where it must neces-
sarily be covered by a splint. Dr. Watson, then my house-
surgeon, applied lint dipped in carbolic acid covered with a
slightly concave piece of sheet-lead about as large as a shilling,
and put up the limb in pasteboard padded with cotton. At
the end of ten da5 r s the inner side of the limb was uncovered
for the first time, and merely as a matter of curiosity, when the
lead, with the lint adhering to it, dropped off, disclosing
a small superficial granulating sore without the slightest suppura-
tion, just as in ordinary healing by scabbing. This case is
interesting, not so much because the compound fracture was
converted into a simple one, for this might have occurred under
ordinary treatment, but because it showed that in any case of
fracture complicated with a small wound, we have in carbolic
acid a means which enables us to disregard the wound alto-
gether after the splints have been applied, instead of being under
the necessity of daily disturbing the apparatus to change the
dressing.
At length a case presented itself well calculated to test the
value of carbolic acid in compound fracture.
Medical Classics
3 6
Case 3. — John H , aged twenty-one, a moulder in an iron
foundry, was admitted on May 19th, 1866, with compound
fracture of the left leg, produced in the following manner. He
was superintending the raising by crane of an iron box containing
sand ready for a casting, the box and its contents weighing about
11 cwt., when one of the chains by which it was suspended
slipped, and the box fell from the height of four feet with un-
broken force upon the inner side of his leg, which was planted
obliquely beneath it. Both bones were fractured, the tibia
about its middle, and a wound an inch and a half in length, and
three-quarters of an inch broad, was made at the inner aspect of
the limb, on a level with the fracture of the tibia, and obviously
communicating with it. At the same time the soft parts gen-
erally were much confused, as was evident from the great dis-
tension of the limb with extravasated blood. Dr. A. Cameron,
my house-surgeon, finding, on manipulating the limb, that
bubbles escaped along with the blood, implying that air had
been introduced during the movements of the leg as the patient
was being carried to the infirmary, thought it best that I should
see the case, which I did at three P.M., three hours and a half
after the accident. In order to expel the air I squeezed out as
much as I could of the clotted and fluid blood which lay accumu-
lated beneath the skin, and then applied a bit of lint dipped in
carbolic acid slightly larger than the wound, and over this a
piece of sheet tin about four inches square. Finally the limb was
placed in pasteboard splints, resting on its outer side with the
knee bent. At eight P.M. some more acid was added with
another piece of lint, so that the crust of clots, carbolic acid and
lint, was about one-third of an inch in thickness. A hot fomen-
tation also was applied over the inner aspect of the leg, the crust
being protected by the tin. Next day he was pretty easy, and
had passed a quiet night, though occasionally awakened by
starting pains; the pulse was 90, but he took some food with
relish. The surface of the crust was touched again with carbolic
acid, and the fomentation was continued, and in place of the
internal pasteboard splint, a large sheet of tin was applied over
the flannel from the knee to the ankle, being retained in position
Compound Fracture, Abscess 37
by looped bandages. This proved a very satisfactory arrange-
ment, the tin having sufficient firmness to answer the purpose
of a splint, which, again, served as an excellent padding. The
fomentation was changed night and morning, and gave great
comfort to the patient, and once a day carbolic acid was applied
lightly to the crust.
Two days after the accident the limb was easier, but the
circumferential measurement of the calf continued the same, and
the pulse was 96, though soft. On the fourth day — the critical
period with reference to suppuration — the limb was free from
pain, and the calf less tense, and distinctly reduced in dimen-
sions; while the pulse had fallen to 80, and the patient had
enjoyed his food after a good night’s rest. After this the swelling
steadily subsided, the skin remaining, as it had been from the
first, free from the slightest inflammatory blush, and his general
health was in all respects satisfactory. Seven days after the
receipt of the injury there was some puriform discharge from the
surface of the skin where the carbolic acid, confined by the
smaller piece of tin that covered the crust, had produced excori-
ation by its caustic action; and to prevent needless irritation from
this cause, the tin was reduced so as to leave only a narrow flat
rim round a bulging part which corresponded to the crust.
About a fortnight after the accident a sense of fluctuation
was experienced over the seat of fracture, but, as all was going
on favourably otherwise, I hoped that this was due simply to
serum from the effused blood; and in a few days it had com-
pletely disappeared, not a drop of pus meanwhile having es-
caped from beneath the crust. About this time the edges of
the crust became softened by the superficial discharge from the
surrounding parts, and these softened portions were daily clipped
away with scissors. Thus the circumferential part of the crust
which had overlapped the skin was removed, and that which
lay over the extravasated blood in the wound was also reduced
to smaller and smaller size.
On the 7th of June, nearly three weeks after the accident,
an observation of much interest was made. I was detaching a
portion of the adherent crust from the surface of the vascular
Medical Classics
3 8
structure into which the extravasated blood beneath had been
converted by the process of organisation, when I exposed a little
spherical cavity about as big as a pea, containing brown serum,
forming a sort of pocket in the living tissues, which when scraped
with the edge of a knife, bled even at the very margin of the
cavity. This appearance showed that the deeper portions of
the crust itself had been converted into living tissue. For
cavities formed during the process of aggregation, like those
with clear liquid contents in a Gruyere cheese, occur in the
grumous mass which results from the action of carbolic (p. 329)
acid upon blood; and that which I had exposed had evidently been
one of these, though its walls were now alive and vascular. Thus
the blood which had been acted upon by carbolic acid, though
greatly altered in physical characters, and doubtless chemically
also, had not been rendered unsuitable for serving as pabulum
for the growing elements of new tissue in its vicinity. The
knowledge of this fact is of importance; as it shows that, should
circumstances appear to demand it, we may introduce carbolic
acid deeply among the blood extravasated in a limb, confident
that all will nevertheless be removed by absorption. A few
days later all traces of the little cavity had become obliterated
by the granulating process.
At the close of the third week the application of carbolic acid
to the crust was discontinued, and the original internal paste-
board splint padded with cotton was again employed, instead of
the tin and fomentation. What remained of the crust was still
kept protected with the tin cap, with the view of ascertaining
how long it would continue to adhere; and at length, nearly four
weeks after the accident, I tore it off from the vascular surface
beneath, which bled as I did so. The crust had preserved the
subjacent parts from disturbance as effectually as if it had been
a piece of living integument; and it is worthy of remark that
the vascular surface below had not the pulpy softness of granu-
lations, but was comparatively firm and substantial. The bit
of crust still smelt of carbolic acid, though none had been applied
for five days.
At the expiration of six weeks from the receipt of the injury
Compound Fracture, Abscess 39
the fragments were found firmly united in good position, just
as if the fracture had been a simple one, though the cicatrisation
of the rather extensive sore was not complete till a later period.
Case 4. — James W , aged ten, was engaged in a turner’s
factory worked by steam power on the 8th of June, 1866, when
his right arm was drawn in between a strap and a shaft turned
by it. He called out for assistance, but thinks two minutes
must have elapsed before the machinery was stopped, and dur-
ing the whole of this time the strap, which was still moving while
he held the arm steady, was cutting into the ulnar side of the
forearm, breaking through the ulna about its middle, while the
radius was bent with “green-stick” fracture. He was taken at
once to the infirmary, where the wound was found to be about
an inch and a half in depth, occupying more than half the cir-
cumference of the limb, chiefly at the dorsal aspect, but extend-
ing round also to the palmar side. The upper fragment of the
ulna was protruding about an inch, and two strips of muscle,
about a quarter of an inch in thickness and from two to three
inches in length were hanging out; the lacerated state of the
parts confirming the boy’s account of the accident.
On seeing him about two hours afterwards, I sawed off the
protruding portion of the ulna, and the tags of muscle having
been previously clipped away, I applied carbolic acid freely to
the whole interior of the wound, including the exposed surface
of the bone; and having straightened the radius, which gave way
during the process, placed the limb upon a wooden palmar splint.
Avoiding any attempt to approximate the lips of wound, I
covered it with a piece of sheet-tin, sufficiently large to overlap
the sound skin about a quarter of an inch in every direction.
The limb was fixed to the splint by a bandage, so arranged as
to permit the removal of the tin without disturbing the appara-
tus; and hot fomentations were applied over the whole. A
few minutes after the carbolic acid was applied he said he was
perfectly easy. At seven o’clock he asked for food, and took
it. His pulse was then 84. At eight P.M. I saw him again, and
applied beneath the tin a piece of lint dipped in carbolic acid,
about as large as the wound. Noticing some distortion in the
Medical Classics
4 °
upper arm, I found that the humerus also was broken in its
lower third, an applied splints accordingly, the limb being kept
supported upon a pillow beside him. He slept a good deal
during the night, though moaning and starting occasionally.
Next day his pulse was 108; but he took his breakfast heartily,
and the tongue was healthy, while he complained only of a little
uneasiness about the elbow, and even this disappeared on chang-
ing the fomentation cloth. A piece of sheet-tin was now ar-
ranged so as to form a sort of cover for the forearm, including
the hand. Being retained in position by looped bandages, it
increased the steadiness of the limb, while it ensured efficiency
of the fomentation.
Two days after the accident the oozing of blood and serum,
which had been considerable during the previous twenty-four
hours, had nearly ceased; but he still experienced comfort from
the fomentation, though any pain which he felt was connected
with the simple fracture of the humerus. His pulse was 88, his
tongue clean and appetite good after a sound sleep at night; and
from this time onward his general health continued perfectly
satisfactory. On the fourth day a small quantity of pale, grey,
slimy discharge was observed from beneath the crust at one part;
and thinking that this might, perhaps, have occurred for want
of proper action of the carbolic acid, I applied the latter with
unusual freedom to the surface of the crust. This was repeated
at night; and the same energetic use of the carbolic acid, twice
in the twenty-four hours, was continued on the fifth day. Yet,
on the sixth day, the discharge from beneath the crust, instead
of being diminished, was increased, and more puriform to the
naked eye; while under the microscope, there was clear indication
of new cell-formation, whereas, on the day before, nothing but
fibrinous material, with granular and other debris, had been
discoverable. On the seventh day the discharge was still greater
in amount; yet the limb remained free from pain, and was
steadily diminishing in circumference, and pressure in the neigh-
bourhood of the crust failed to induce any increase of the dis-
charge, which appeared to be merely superficial.
In the course of the next few days it became apparent that
Compound Fracture, Abscess 41
this discharge, so far from being the result of insufficient action
of the carbolic acid, was caused by the stimulating influence of
the acid itself, applied with greater freedom over a crust much
thinner than that of Case 3. Suppuration from this cause is,
however, productive of no mischief, as will be better understood
from the sequel. That such was the case in this instance was
manifest on the fourteenth day, when the crust, which was
nearly detached, was removed, disclosing an appearance for
which I confess I had not been prepared. In place of the deep
and ragged wound was a granulating sore, nearly on a level
with the skin, and pretty uniform in surface, except at one part
about its middle, where there was a depression about half an
inch in depth, at the bottom of which a small portion of the
outer surface of the ulna was visible, bare, but of pink colour.
Not only had the compound of blood and carbolic acid which had
existed in the depths of the wound been organised, but the por-
tions of tissue killed by the violence to which they had been
subjected in the accident, and also those destroyed by the caustic
action of the carbolic acid, had been similarly acted on, and
all had been, so to speak, fused together into a living mass,
without the occurrence of any deep-seated suppuration.
By the nineteenth day the exposed part of the bone was cov-
ered, and the depression in the sore obliterated by granulation,
without any exfoliation occurring; and two days short of seven
weeks after the accident the sore was entirely healed.
The extensive loss both of bone and of the soft parts made
osseous union of the ulna a matter of difficulty, and on the
5th of August the limb was placed in a starched apparatus, to
promote complete consolidation, and he was soon after dis-
charged from the hospital.
About six weeks later he presented himself at the infirmary,
and the bandage was removed in my absence, when, the bone
appearing firm, he was allowed to dispense with the apparatus,
and was unfortunately not directed to show himself again. In
the course of a few weeks, however, he appeared with the frag-
ments again movable. The starched bandage was therefore
reapplied, but when I last saw him, some weeks ago, bony union
Medical Classics
42
had not yet occurred. A good deal of osseous formation had,
hov/ever, taken place, so that the fragments now overlapped
each other; and should the cure be still incomplete when he next
shows himself, the case will be a fair subject for Bickersteth's
method of treating ununited fracture by drilling. Meanwhile,
the radius being firm, and the injured extensors of the fingers
having completely regained their powers, he will, in any event,
have a very useful hand.
This case indicated a greater range of applicability of the
treatment by carbolic acid than I had anticipated, and encour-
aged me to employ it under the almost desperate circumstances
of the following case.
(p. 357) Case 5. — Charles F , a fine, intelligent boy, seven
years of age, was knocked down at eight P.M. on June 23rd,
1866, by an omnibus crowded with passengers inside and out,
and one if not both wheels passed over his right leg, breaking
both the bones and inflicting a frightfully extensive wound. The
person who brought him to the infirmary said that he had lost
a great deal of blood, and the presence of a compress in the ham,
placed there by the medical man who saw him at the time of the
accident, corroborated this statement. When I saw the child,
after an unavoidable delay of three hours, he was greatly pros-
trated by shock as well as hemorrhage, so much so that amputa-
tion appeared likely to afford but a slender chance of life, al-
though the state of the injured parts seemed at first sight to
admit of no alternative. The tibia, which was broken about its
middle, lay exposed in a wound occupying almost the entire
length and breadth of the inner aspect of the leg, reaching from
the inner condyle of the femur to within an inch and a quarter
of the tip of the internal malleolus; the skin having been stripped
back so as to lay bare the gastrocnemius as well as the bone.
The large flap of integument was perforated about two inches
from its edge opposite to the seat of fracture, and there was also
an opening in the skin on the outer side of the leg, implying that
the violence had acted with full effect upon the whole thick-
ness of the limb. Yet the bone was not comminuted, and the
muscles, though evidently severely contused, were not much
Compound Fracture, Abscess 43
lacerated, while the anterior tibial artery was felt beating in the
foot; and, hopeless as would have been the idea of trying to save
the limb by ordinary treatment, I determined to make the at-
tempt by the help of carbolic acid.
Chloroform having been administered, the acid of full strength
was applied with great freedom, the contused mass being re-
peatedly squeezed, to induce the liquid to insinuate itself into
all its interstices, including that between the riding fragments of
the tibia. The flap of skin was then brought towards its natural
position, and lint soaked in the acid was placed under the wide
raw surface which still remained exposed, and over the lint a
piece of sheet tin. The other openings in the integument were
similarly treated; and, the riding of the fragments having been
corrected by extension, the limb was laid on its outer side, with
the knee bent, upon an external pasteboard splint, moulded to
the leg and foot, and strengthened by a temporary wooden
splint. A porous cloth was applied over the tin to absorb the
blood and serum which must escape from beneath its edges ;
and the whole apparatus was secured with a roller. At the con-
clusion of the dressing the pulse was 112.
He passed a restless night, though occasionally dozing, (p. 358)
and the pulse next morning was 120. The bandage having been
cut away sufficiently to enable the tin to be removed, the wound
was found to have gaped so that the lint no longer covered the
whole of it. Pieces of the cloth, which had become soaked
with the exuded blood, were placed upon the exposed part, and
also over the lint so as to make the crust more substantial, and
the whole was freely treated with carbolic acid. The tin was
then bulged out so as to be accommodated to the thickened
crust, while overlapping the neighbouring skin to a slight extent;
being retained in position by a couple of turns of bandage. A
hot fomentation was then placed upon the inner aspect of the
limb, and the whole leg enveloped in a large sheet of block-tin
secured by looped bandage.
In the evening the pulse was 136, and on the following morn-
ing, thirty-six hours after the accident, it had risen to 168, and
was very weak. He lay talking to himself in a rambling manner.
Medical Classics
44
unable to understand what was said to him. He was extremely
restless, and had taken no food whatever since his admission.
During the next night, however, he became composed, and took
a little milk; and on the morning of the third day he was found
to be again intelligent, while the pulse had fallen to 140, and was
of fair strength. The skin in the vicinity of the injury, both at
the knee and ankle, was free from discoloration or swelling; but
part of the large flap of skin over the calf was of purple tint, and
had evidently lost its vitality. This dead part was touched with
carbolic acid, to preserve it from decomposition, and convert it
into a crust for the protection of the subjacent textures, and an
additional piece of tin was applied to cover it. A good deal of
brown transparent fluid escaped from beneath the crust.
On the fourth day the pulse was 120; he was quite bright and
tranquil, and said he felt no pain. There was still no odour
about the injured part, except that of carbolic acid. The dis-
charge was much diminished, and was principally serous.
By the sixth day the pulse was as low as 108. He had a hearty
appetite, and also took with avidity the six ounces of port wine
allowed him during the twenty-four hours. His tongue, which
had previously been dry, v/as moist. He had slept well at night,
though waking occasionally v/ith a scream. The discharge from
beneath the crust, trifling in amount, was chiefly serous.
On the eighth day the splint was removed for the first time,
and v/as covered v/ith sheet-tin in order to prevent the dis-
charge from softening the pasteboard. The leg had become
slightly bent inv/ards through the yielding of the splint; and
v/hen It v/as now straightened, the upper margin of the crust
became detached, exposing a deep granulating cavity. A bit of
lint, dipped in carbolic acid, v/as applied lightly over this open-
ing, and the tin v/as readjusted so as to cover it. Pressure in
the neighborhood of the injured part, about the knee, ankle,
and calf, failed to induce the slightest increase of the discharge,
which v/as thus shown to come merely from the surface beneath
the crust, and v/as still for the most part transparent.
At the close of the second v/eek his state was on the v/hole
very favorable. His general health v/as much improved; and
Compound Fracture, Abscess 45
although he still suffered occasionally, especially at night, from
restless movements of the limb, these had been much restrained
by a new splint, extending from half way up the thigh to the
toes. The wound was certainly very large, measuring eight
inches in length by six in greatest width; but it was healing round
almost the entire circumference. In order to permit cicatrisa-
tion, which carbolic acid tends to check, the detached edges of
the crust had been clipped away, and the exposed narrow ring
of granulations was dressed with lint dipped in a solution of
sulphite of potash — five grains to an ounce of water. The crust,
however, was still touched daily as before with carbolic acid,
while the tin still covered the whole of the injured part. By
this means it was intended that cicatrisation should be allowed
to go on, and yet decomposition of the discharge be prevented;
and this seemed to be to a great extent, if not entirely, attained.
There was, however, one unfavourable circumstance. The
little sore on the outer side of the leg, which had been dressed
separately without carbolic acid, and had for some time been
observed to be increasing rather than diminishing, now assumed
unmistakably the appearance of a mild form of hospital gangrene,
and became blended with the main sore. For two days an at-
tempt was made to correct the disease by touching the affected
part with nitric acid; but on the eighteenth day it was clear that
some more effectual measures must be adopted, as the skin in
the vicinity had become insidiously undermined to a very serious
extent. Accordingly I placed the boy under chloroform, and
scraped away with a spoon all the soft grey sloughs, slitting up
the skin in order to gain access to them, and in some parts clip-
ping portions of it away, and then applied the strongest nitric
acid thoroughly to the bleeding surface. As the disease ex-
tended up to the anterior edge of the crust, I thought it right to
examine the state of the parts beneath, and as it was prett) loose
I removed it. And now a sight presented itself which filled me
with horror. There was, indeed, no appearance of hospital
gangrene in the parts which the crust had covered, the granu-
lations there having the florid aspect of perfect health; bu<. m
the large sore lay the lower fragment of the tibia, freel} cxpo.>
Medical Classics
to the extent of two inches and a half in length, bare and white
like a macerated bone. At the upper end of this fragment, and
apparently for a considerable distance from it, the bone was
thus denuded round its entire circumference; and, judging from
previous experience, there was reason to expect that, even if the
patient should survive the profuse suppuration which was to
be anticipated, about two inches of the whole thickness of the
tibia must exfoliate, an amount of loss which, in the child’s
small limb, would of necessity render it utterly useless. The
upper fragment was also bare for about half an inch just above
its extremity, but the end itself was covered with prominent
granulations.
Though despairing of any good result, I resolved to watch for
a while the progress of events, prepared to amputate as soon as
the boy’s health should show signs of failing; and comforting
myself with the reflection that he had been brought into a state
greatly more favourable for the operation than on his admission.
In order to keep down the amount of the discharge the sore was
dressed with the sulphite of potash lotion, a poultice being
applied to the part which had been treated with nitric acid.
When the sloughs caused by the caustic separated a healthy
surface appeared, which in the course of the next ten days was
nearly healed. In other parts of the sore, however, grey patches
occasionally showed themselves, assuming healthy characters
after being touched with carbolic acid, which, when efficient, has
the advantage over other caustics of being painless. But at
length spots of hospital gangrene appeared in a form no longer
amenable to this mild treatment, in spite of which they began to
extend rapidly, and on the 26th of July it became necessary to
put the child under chloroform and apply nitric acid in the same
thorough manner as before. This had the effect of producing a
perfectly health state of the whole sore, which proceeded to heal
with great rapidity; so that by the 8th of August it was found to
measure an inch less in length and two inches less in greatest
breadth than at the time when the crust was removed.
In the meantime his general health, instead of deteriorating,
had improved, and he was evidently regaining flesh, while the
47
Compound Fracture, Abscess
discharge of pus was astonishingly little considering the state
of the limb, being barely sufficient to soak the single layer of
lint that covered the sore.
The explanation of this satisfactory state of things was af-
forded by an observation of much interest made at this period.
Since the removal of the crust the granulations had been growing
up on all sides about the bone, so that the bare part of the upper
fragment was almost entirely covered in, and even the lower
fragment, which projected beyond the level of the upper, was to
a great extent embedded in the new growth. It had been
noticed before the end of this fragment was so much covered up,
that granulations were sprouting from the medullary canal,
showing that the bone was not dead in its entire thickness.
Nevertheless, as the superficial parts had certainly lost their
vitality, I had not doubted that a thin layer at least must exfoli-
ate from the whole. Now, however, I observed that some of the
surface which remained exposed had assumed a pink colour,
implying that the layer of dead bone, whatever its thickness
might have originally been, had become so thin as to be trans-
parent, through absorption by new tissue growing in the interior.
Further, on attempting to pass the eyed end of a probe between
the tibia and the granulations which had enveloped it, I found
to my surprise that the instrument could only be introduced for
a very short distance, the granulations, with the exception of a
narrow free border, being everywhere adherent. The new tissue
outside the bone had coalesced with that within, after complete
absorption of the intervening dead stratum. Hence the remark-
able absence of discharge from around the bone.
During the following month I was absent from home, but was
informed that the same process was for some time continued:
the granulations gradually encroaching more and more on the
exposed bone, and adhering to it as they advanced. The upper
fragment was thus entirely covered without any exfoliation oc-
curring, and the bare surface of the (p. 359) l° wer fragment was
reduced to comparatively small dimensions. On the ioth of
September the remainder of the dead part, being loose, was
removed without difficulty as an exfoliation. It was about an
Medical Classics
48
inch in greatest length; but was of extremely irregular shape,
full a quarter of the circumference of the tibia being deficient.
At the upper end, where it had been most prominent and had
become discoloured, it had nearly the full thickness of the dense
tissue; but towards the lower end it became thinned away, so
as to be in some places as delicate as tissue-paper. The outer
surface presented near the margin an appearance of especial
interest, being at some parts, even where the bone had consid-
erable thickness, variously scooped and bevelled in a manner
that admitted of no other explanation than that the granula-
tions overlapping the dead bone externally had been engaged
in its absorption. On applying a magnifier to these excavations
in the external surface, they were seen to present a peculiar vel-
vety aspect, differing from the rest of the exterior, but resembling
the internal parts of the exfoliation.
The only observation at all analogous to this with which I
am acquainted is that of the effects produced upon the ivory
pegs used in Dieffenbach’s method of treating ununited frac-
ture, the parts of the pegs driven into the bone having been ob-
served, when removed, to have suffered diminution in size.
This has hitherto remained as an isolated fact, and it has been
regarded as an axiom in surgery that a piece of bone once dead
must all come away as an exfoliation. Why it was that in the
case before us the osseous tissue destroyed by external violence,
aided by the action of carbolic acid, was so exceptionally affected
by surrounding parts, the granulations in its vicinity discharging
the office of absorbents of the dense tissue, instead of forming
pus like those around an ordinary exfoliation, I will reserve for
future discussion, when I shall have occasion to point out the
great importance of the fact in its bearing both on pathology
and practice. Meanwhile I may remark that it illustrates
beautifully the function of absorption, which, even where solid
substances are taken up, does not require any special set of
absorbent vessels, but may be effected even by granulations, the
most rudimentary of all tissues, each cell feeding upon any
suitable substance in its vicinity.
We also see at once the value of the observation with refer-
Compound Fracture, Abscess 49
ence to the treatment of compound fracture with carbolic acid;
for it shows that in cases in which the bone is exposed, the acid
may be applied so freely as to cause death of its tissue without
necessarily inducing exfoliation.
The case was now reduced to one of simple fracture with a
large granulating sore, and this was greatly diminished and
healing rapidly, while the union of the fragments was becoming
very hr m; and the limb would doubtless soon have been entirely
sound had it not been for that cruel scourge, hospital gangrene.
This, however, had shown itself ten days before the removal of
the exfoliation, not in the sore, but about an inch from its edge,
as a pustule in the cicatrix, which on bursting disclosed a grey
slough that soon showed its characters unmistakably, producing
considerable destruction of the scar, although the original sore
continued to heal kindly.
I will not enter into the history of this and numerous subse-
quent attacks of the disease further than to state that they
were partial in their effect, the unaffected parts still healing with
rapidity, and that they continued to yield to the treatment with
nitric acid; so that at one time the whole sore was very nearly
healed.
But in the early part of October the disease assumed a more
intractable form, and in spite of the most energetic use of nitric
acid on several occasions, which produced illusory appearances
of temporary improvement, by the 27th of the month the sore
had become enlarged to nearly its original dimensions, while
the limb had swollen greatly through inflammation caused by
the irritation, and the boy’s general health was rapidly giving
way under the increased discharge and nervous excitement.
The question of amputation now again presented itself, but
a good airy room in a different department of the hospital being
happily now at my disposal, I determined to give the limb one
last chance. Before he was taken to the new ward, nitric acid
was once more thoroughly applied. His nurse was directed to
change the poultice every three hours, and he continued to take
wine and some tonic medicine. His general health immediately
improved, and when the slough separated, the sore looked
Medical Classics
5 °
healthy. It was now dressed with lint dipped in a solution of
sulphate of copper, five grains to an ounce of water, and over this
a poultice, the whole being changed every three or four hours
night and day; and under this treatment cicatrisation proceeded
rapidly. Yet when the scar had attained a certain width, a
tendency to vesication again showed itself threatening recurrence
of the disease, and in order to prevent the newly-formed epi-
dermis from acquiring poisonous qualities as it seemed to do, I
ordered the lint with the lotion, as well as the poultice, to be
extended over the whole cicatrix. From the time this dressing
was adopted the progress was uninterruptedly satisfactory till
the 9th of January, when the sore was at length entirely healed,
and he was allowed for the first time to put his foot to the
ground. The contraction of the large cicatrix, involving at one
part the gastrocnemius muscle, had caused some bending of the
knee and pointing of the toes. The former has since become
corrected spontaneously by his habitual attitude, sitting in bed
with the legs extended before him. The pointing of the toes
has also become diminished, and will probably soon pass off
entirely, without the division of the tendo Achillis, which I
had in view. The tibia, which has long been firm, is of precisely
the same length as the other, and the contour of the limb is
natural. His general health also is excellent; but he was de-
tained in the hospital till the 9th inst. (March, 1867), on account
of an obstinate eczematous eruption on the integument of the
leg irritated by the long-continued poulticing.
(p. 387) case 6. — The following case terminated fatally, but
from circumstances of an accidental nature; and I trust that the
instruction to be derived from it will not be interfered with by
the unhappy ultimate result.
John C , aged fifty-seven, a labourer, was working in a
quarry at Row, near Helensburgh, on the Clyde, at nine A.M.
on Oct. 26th, 18 66, when, striking with a crowbar an overhang-
ing part, he brought down an enormous mass of stone weighing
six or seven tons, which fell in large blocks on and about him.
His right thigh-bone was broken in its lower third, and, as after-
wards appeared, the end of the upper fragment was driven
Compound Fracture, Abscess 5 1
through the skin at the inner aspect of the limb a little above the
knee. The right collar-bone was fractured at the same time,
and he was severely contused in other parts. It was long before
his only companion in the quarry could extricate him from his
position, and the procuring of a conveyance involved further
delay; so that a considerable period elapsed, during which he
lost much blood from the thigh, before he could be taken to
Helensburgh. Here he was placed on a litter, with a warm
moist blanket round the limb, with the object, as he said, of
checking the bleeding, which, however, it could not but tend to
encourage. He was then conveyed by train to Glasgow, where
he reached the infirmary six hours after the occurrence of the
accident.
Dr. Archibald Cameron, the house-surgeon, seeing the case
to be a very grave one, at once sent for me, but without any
delay introduced carbolic acid into the wound by means of a
piece of lint held in a pair of dressing forceps, passing by means
it about an inch in every direction beneath the integument, after
squeezing out a considerable quantity of extravasated blood
from the orifice, which was large enough to admit the tip of
the finger.
On arriving, an hour after the patient’s admission, I found him
in a state of prostration sufficiently explained by the severity
of his injuries and by the blood lost to the circulation, including
a large amount extravasated in the limb, and distending, not
only the whole thigh, but the calf, the tenseness of which con-
trasted strikingly with the flaccidity of the other.
Under these circumstances decomposition of the blood effused
among the tissues would have been necessarily fatal. And yet,
considering the length of time that had elapsed since the receipt
of the injury, and the fact that a reeking flannel had been for
two hours in contact with the wound, and had already a some-
what offensive odour when removed from it, there seemed but a
poor chance for the treatment with carbolic acid. On the other
hand, taking into account the man’s time of life and general
condition, I believed that to amputate through the thigh infil-
trated with blood would be certainly to kill him. And there ore,
52 Medical Classics
as it was impossible to say that the other treatment had no
chance, while, if it should prove successful, it would have the
immeasurable superiority of saving limb as well as life, I deter-
mined to persevere with it.
Having removed from the wound the dressing placed on it by
Dr. Cameron, I forcibly squeezed out a further large amount of
blood, and applied carbolic acid in lint and also mixed with
blood, so as to provide for a crust of considerable thickness over-
lapping the skin by about half an inch every way. This was
covered with a circular piece of tin, two inches across, well bulged
out except a flat margin about a quarter of an inch wide, which
rested on the surrounding integument. This tin cap was re-
tained in position by a single turn of bandage tied round the
limb.
The lower end of the upper fragment was much displaced
downwards in the vicinit5 r of the wound, but returned towards
its natural position on extension of the limb. There still re-
mained considerable depression anteriorly over the seat of frac-
ture; but the lower fragment did not seem to project towards
the ham so much as to forbid the use of the long splint. This
I accordingly employed with two interior splints to support the
muscles of the thigh, one of Gooch’s material on the outer aspect,
the other a large sheet of stout block tin, embracing the anterior,
inner, and posterior aspects of the limb to a little below the knee,
padded in the first instance with a dry towel, for which a hot
fomentation should be substituted when all tendency to hemor-
rhage should have ceased. The object of having the tin extend
round the back of the thigh was that it might prevent the dis-
charges from soaking into the bed beneath; and in this way it
proved extremely useful.
He passed an uneasy though not entirely sleepless night,
suffering more from his shoulder and bruised side than from
the thigh. Next morning his aspect was favourable, the pulse 76,
and tongue natural; he took a little tea for his breakfast, but
nothing solid. The tin cap having been removed, care being
taken to avoid detaching the crust along with it, carbolic acid
was applied to the surface of the latter. A hot fomentation
Compound Fracture, Abscess 53
cloth was then placed on the inner side and front of the thigh
and gave him great comfort, and when the dressing was com-
pleted he was quite easy. The interior splints being kept in
position by looped bandages, and the long splint by the usual
folded sheet fixed by pins, along with the perineal band and
handkerchief round the foot, the fomentations could be changed
night and morning without any disturbance of the limb.
The following night he had a good deal of sleep, the thigh
not causing him any inconvenience; and next day, the third
after the accident, he took solid food with relish. His pulse was
72, and his tongue continued moist, though he was somewhat
thirsty. The crust was touched again with carbolic acid, and
covered with a circular piece of calico. to prevent the tin cap from
adhering to it. He still found comfort in the fomentations.
On the fourth day he made a substantial breakfast after a
good night’s rest, and was not so thirsty. There was, however,
now seen for the first time a slight blush of redness on the front
of the thigh over the seat of injury. This was on the fifth day
somewhat increased, and the thigh and calf were both more
swollen. The tongue also was slightly furred at the base,
and his appetite was not quite so good.
On the sixth day the dimensions and appearance of the limb
were unaltered, but on the seventh both the redness and swelling
were distincly diminished.
By the end of the second week his appetite was improved and
his pulse was 76; while there had not been a drop of discharge
from beneath the crust, which had been still touched daily with
carbolic acid, the fomentations also having been continued. The
swelling, however, had not subsided, and the redness, though
varying in extent and degree, had never disappeared from over
the seat of fracture. On the fifteenth day a defined prominence
made its appearance at this part in a space about as large as
the palm of the hand, a little further forward than the crust,
and a sense of fluctuation was to be perceived in it. In the
evening Dr. Cameron, on changing the (p. 3^8) fomentation,
saw more pus than he thought could be accounted for by the
superficial excoriation round the crust, and next morning, on
Medical Classics
54
removing the flannel, I found it soaked with similar discharge;
a considerable quantity also lying between the tin splint and the
limb. On raising the tin cap, the matter was seen welling out
from beneath the lower edge of the crust. It was perfectly free
from odour, confirming the conclusion I had previously arrived
at that this abscess was not in any way caused by decomposition
from atmsopheric influence. The long period that elapsed be-
fore it made its appearance, together with the absence of any
serious constitutional disturbance, clearly showed that the car-
bolic acid had effectually answered the purpose for which it was
applied, the constant oozing of blood from the small wound
having doubtless been in the patient’s favour, by preventing
decomposition from penetrating far into the interior before he
came under treatment. We know that a mass of extravasated
blood occasionally becomes the seat of suppuration without the
existence of any external wound. A curious instance of this
occurred lately in my practice, in a boy who fell down the hold of
a ship upon his head, and, besides serious cerebral symptoms,
exhibited at once a remarkable prominence of the right eyeball,
evidently due to extravasation of blood into the orbit. There
being no wound, I expected that the blood would be absorbed;
but after the lapse of several days, the prominence of the eye
showed increase rather than dimunition, and the boy began to
complain of supraorbital pain. Fluctuation then became per-
ceptible, and pus was evacuated by incision, after which the
eyeball gradually resumed its natural position.
Such I supposed to be the nature of the abscess in C ’s
case, and previous experience made me fear that, if decomposi-
tion of its contents should occur, the irritation of the fetid pus
might cause very serious consequences from rapid extension of
suppuration among the imperfect and feeble products of the
organisation of the blood in the yet swollen limb.
Hence I had intended to evacuate the matter by aid of carbolic
acid in such a way as to prevent decomposition. As the abscess
was not near the surface at the part where it appeared to be
pointing, I had reckoned on having plenty of time for my opera-
tions, and was greatly disappointed to find that it had discharged
itself spontaneously.
Compound Fracture, Abscess 55
Nevertheless, as the pus was proceeding from beneath the
crust impregnated with carbolic acid and was still quite odour-
less, I did not altogether despair of attaining my object. In
order to make the crust more effectual, I extended it for about
three-quarters of an inch at the part from which the pus was
escaping, by a piece of lint dipped in carbolic acid, which, when
mixed with pus, forms a sort of curdy mass which answered pretty
well for a crust. A considerable quantity of matter, of moderate
consistence and greenish white colour, was then pressed out
from the limb. A new tin cap having been made, large enough
to cover the whole of the extended crust, the fomentation was
continued as usual.
Next day it was evident, from the sense of fluctuation, that
reaccumulation had occurred in the abscess, but no further dis-
charge had taken place. On removing the tin cap, however,
pus was seen to well out from a new situation at the upper edge
of the crust. A piece of lint dipped in carbolic acid was at once
placed on this part, and the matter was pressed out and carefully
collected, measuring 3 oz., of moderate consistence and yellowish
white colour, still without odour except that of carbolic acid.
The crust having been somewhat extended at the situation of
the new opening, the whole was freely treated with carbolic
acid, the tin cap readjusted, and fomentation continued.
During the rest of the week that followed the first evacuation
of the abscess the same treatment was pursued with the most
satisfactory results. Some pus was usually seen on the foment-
ing flannel both morning and evening, and some was pressed out
of the limb from the orifice last formed, but the amount rapidly
diminished in quantity, and also became thinner and more trans-
parent, while it continued free from odour. It may be worth
while to mention in detail the quantities obtained from the limb
in the morning of each of these days. On the seventeenth
day it was an ounce and a half, somewhat thinner than before;
on the eighteenth, two drachms and a half, decidedly thinner,
on the nineteenth, half a drachm, much thinner and more
transparent; on the twentieth, a quarter of a drachm, similar in
quality, and on the twenty-first, six drops only, and almost free
Medical Classics
from opacity. Finally, in the evening of that day no discharge
was seen on the flannel, nor could any be squeezed out from the
limb. Meanwhile the calf, which had increased markedly in cir-
cumference just before the abscess opened, steadily diminished,
and in the thigh all swelling disappeared from over the seat of
fracture, so that the end of the upper fragment, previously quite
obscured, could be distinctly defined. His general health, too,
had improved; his tongue had become quite clean, and he had
acquired for the first time since his admission a genuine appetite,
the pulse continuing about 72.
I suspect, however, that this success made us relax a little
our vigilant care in guarding against decomposition. But be
this as it may, the method which we pursued in order to avoid
it was not, as experience has since shown, thoroughly trust-
worthy. Would that I had at that time known of the mode of
proceeding which will be found described in a future section of
this communication. Very different then might have been the
issue of the case!
On the twenty-second day pus was again found in the flannel,
and some bubbles of gas were observed to escape along with
the two or three drops that could be squeezed from the limb,
and these had a distinctly offensive odour. Judging it now use-
less to retain the crust any longer I removed it, and found the
original wound still sealed by the original clot, the openings by
which the pus had escaped being new apertures in the skin over-
lapped by the crust. In the after part of the day he had a good
deal of uneasiness, and in the evening half an ounce of pus, with
numerous air-bubbles, was pressed out of the limb by Dr.
Cameron. After this the patient passed a comfortable night,
and in the morning only two drachms of matter could be pro-
cured from the thigh, but this was thicker and more opaque than
it had been, with decidedly offensive odour, and contained bub-
bles of gas; there was also pus in the flannel. There was, further,
some return of welling over the seat of fracture.
But though the plan of dealing with the abscess had failed to
accomplish all that I desired, its essential object appeared to
have been attained. For during the week in which decomposi-
Compound Fracture, Abscess 57
tion was prevented, the thigh had become so much consolidated
and strengthened that all danger of serious consequences seemed
to have been tided over. No extension of the suppuration took
place beyond the trifling degree above described, and his con-
stitution did not suffer. Any further use of carbolic acid being
obviously uncalled for, the sore was simply dressed with a lotion,
the lint being so arranged as to allow free escape for the pus,
and afterwards, to promote this more effectually, a small per-
forated caoutchouc tube was introduced, a dry cloth being sub-
stituted for the fomentation. Under this management the dis-
charge gradually diminished in quantity, and became again
thinner and more transparent, and the swelling of the calf be-
came steadily reduced.
Still the opening did not close, and on the 2nd of December,
more than a fortnight having passed in this way, I introduced a
probe, and found that it passed downwards to bare bone, including
a considerable extent of surface in the lower fragment. Here,
then, was presented the prospect of a tedious process of exfoli-
ation; whereas if decomposition of the pus had not occurred,
the granulations would probably have closed upon the dead bone,
and absorbed it, as in the last case, and the fact that any part
had lost its vitality would then never have been known. That
there is a reasonable ground for this belief will, I trust, appear
from the discussion in the succeeding section.
For a long time the progress of the patient continued satis-
factory, the process of union of the fragments advancing steadily,
till in the early part of February, the bone being firm, the splints
were entirely discarded, and the case was reduced from one of
fracture to one of limited exfoliation. It was satisfactory also
to find that the knee-joint continued movable, so that I confi-
dently anticipated recovery, with a perfectly useful limb.
At this period, however, a new symptom presented itself
viz., hemorrhage from the sinus. Mr. Hector Cameron, my
present house-surgeon, who saw the first appearance of bleeding,
supposed it to proceed from the surface of the granulations, for
it was then small in amount, and ceased spontaneously. Some
days later, however — viz., on the nth of February, a very
Medical Classics
58
profuse hemorrhage occurred, the blood soaking through the
bed, and dropping upon the floor beneath, before it was observed,
and the gentleman who was summoned to see the patient in
Mr. Cameron’s absence, found him pulseless. He afterwards
rallied to some extent, but remained utterly prostrated, and
unable to retain the slightest nourishment. As the popliteal
artery could be felt beating in the lower part of the ham, I hoped
that the source of the blood might be some minor branch, which
might possibly close. But it afterwards appeared that a circu-
lar opening existed in the main vessel, occasioned no doubt by
the pressure of an irregular projection of the lower fragment. It
would be irrelevant to relate particularly the history of his yet
further exhaustion by recurrent hemorrhages after delusive
temporary cessations, or of my attempts to restore him by tying
the popliteal artery, and making arrangements for transfusion,
to which he declined to submit. He died on the 25th of
February.
(p. 507) The next four cases occurred in the practice of my
colleagues in the infirmary, who have kindly placed them at
my disposal.
Case 7. — Mary M , aged sixty-two, was admitted under
the care of Dr. Morton on August 13th, 18 66, at eleven P. M.,
when she stated that about five o’clock in the afternoon of that
day she missed her footing when going down stairs, and fell
with violence, and on getting up found that her right forearm
was broken and bleeding. A medical man was called in, who
made various applications in order to stop the hemorrhage, but
failed to do so, and she was advised to go to the infirmary. Mr.
A. T. Thompson, the house-surgeon (to whom I am indebted for
notes of the case), on removing the bandage, from which blood
was trickling, found both bones of the forearm broken a little
above the wrist, and a detached fragment of the radius project-
ing from a wound about as large as a fourpenny-piece, on the
outer aspect of the limb. Having extracted this fragment, he
applied liquid carbolic acid thoroughly to the interior of the
wound. This rather increased the bleeding, which, however,
he arrested completely by plugging the orifice with a bit of lint
Compound Fracture, Abscess 59
dipped in the acid. Over this he placed a mixture of blood and
carbolic acid, covering it with a piece of dry lint. He then
put up the limb in two well-padded Gooch’s splints, retained in
position with a continuous bandage. The apparatus was left
undisturbed for five days, when, on removal of the splints, it
was found that the piece of dry lint over the wound, though it
had been saturated with blood, was quite dry, having become
incorporated with the crust beneath. It was not interfered with
except that the surface was touched with carbolic acid, and the
splints were reapplied as before, the part being quite free from
uneasiness.
On the twelfth day the splints were again removed and the
crust was detached, when it was found that the piece of lint
with which the wound had been plugged had become partly
pushed out of the orifice. The plug also was now removed, when
the surface beneath was observed to be granulating, but entirely
free from pus. The sore was dressed with one part of carbolic
acid to seven parts of olive oil applied on lint every second day,
the use of the splints being continued till the 8th of September,
when she was discharged, with the sore healed and both bones
firmly united, two days less than four weeks after the accident.
This case is valuable as an example of a mode in which trouble-
some bleeding in compound fracture may sometimes be advan-
tageously arrested. The entire absence of pus about the plug
on the twelfth day after its introduction contrasts strikingly
with the suppuration invariably caused within four days by a
piece of lint inserted without carbolic acid into a wound.
Case 8. — Samuel B , aged thirteen, was admitted under
Dr. Morton’s care, on Aug. 3°th, 1866, with a compound frac-
ture of the left femur, about the junction of the upper and middle
thirds of the shaft, and a simple fracture of the right thigh in
a similar situation. He started that about four hours previously
he was engaged in some work about a steam-engine, when he was
struck by one of the balls of the “governor, and hurled with
great force against an iron pillar. The men who brought him
to the infirmary said that when he was raised from the ground
a piece of bone was seen to protrude from a wound in the left
6o
Medical Classics
thigh, but was restored to its natural position by a medical
man who was called in to see him, and who applied a long splint
and bandage to each limb. Mr. A. T. Thomson, on examining
the boy, found a lacerated wound about three inches long at the
upper part of the left thigh, running transversely from, the mid-
dle of the inner side of the limb to its posterior aspect, and in
this wound the upper fragment of the femur was visible, some-
what displaced, but not protruding. There was some bleeding,
but not to any serious extent. He sponged out the wound
thoroughly with a solution of one part of carbolic acid in three
parts of olive oil, and then covered its bps with a mixture of
blood and the undiluted acid spread upon lint, and over this a
piece of sheet-tin, retained in position by means of a looped
bandage. He next corrected the faulty position of the fragments
and applied lateral splints of Gooch’s material to the thigh,
maintaining gentle extension by means of plasters applied to the
integument of the leg after the American plan, and fixed to the
foot of the bed, a perineal band being attached to the bed-
head. While the left limb was thus kept readily accessible for
changing the dressings, the long splint was employed as usual
for the simple fracture on the right side.
Next day the surface of the crust was touched with carbolic
acid, and a hot fomentation applied to the limb.
On the third day the crust was removed through a misunder-
standing, but it was resolved to follow out the treatment on the
same principle, and with this view the wound was dressed twice
a day with lint dipped in the mixture of carbolic acid and oil
(one part to three), covered with the tin, as the crust had been
before, while the fomentations also were continued. Meanwhile
the limb remained free from pain, redness, or swelling, and there
was a complete absence of constitutional disturbance.
On the sixth day, however, he was a little feverish, and re-
mained so, though without any apparent local symptoms, till
the twelfth day, when Mr. Thomson noticed that the central
part of the wound, which had become covered with a whitish
crust, was somewhat prominent, and, on careful examination,
perceived a distinct sense of fluctuation. He therefore removed
Compound Fracture, Abscess 61
the white layer from that part, when eight ounces of perfectly
odourless pus escaped. A probe introduced failed to detect
any bare bone. Mr. Thomson now sponged out the cavity of
the abscess with the mixture of carbolic acid and oil, and left
in it a strip of lint dipped in the same, continuing the other dress-
ings as before. The constitutional disturbance now at once sub-
sided, and under the same dressing the cavity of the abscess
quickly contracted, and in a little more than a fortnight closed
entirely. Six weeks after the accident the wound was completely
healed, and both the thigh-bones were firmly united, with the
limbs of equal length. In another week he was able to stand.
This case, which, I cannot avoid remarking, reflects great
credit on the house-surgeon in charge, is interesting as another
instance of the occurrence of abscess in compound fracture,
independently of atmospheric influence. That it was so in
this instance is clearly shown by the entire absence of constitu-
tional symptoms for the first five days, the circumscribed char-
acter of the suppuration, and the odourless nature of the pus.
The injured part suppurated, probably, from the same cause as a
severe bruise may without any breach of the integument. The
satisfactory results obtained by treating the wound with carbolic
acid diluted with oil, instead of the undiluted acid, will naturally
suggest the inquiry whether this would not always be the better
practice. And I may mention that my former house-surgeon.
Dr. A. Cameron, met with similar success in two cases in which
he pursued the same treatment — one of them a compound frac-
ture of the ulna at the elbow, the other a severe contused wound
of the back of the hand communicating with a fractured meta-
tarsal bone. But considering how much is at stake, and that
the patient’s life may depend upon entire destruction of the sep-
tic germs that lie in the wound, I am inclined to think it wiser
to avail ourselves of the full energy of the pure acid, more es-
pecially since we have had sufficient evidence that any caustic
effects it may have are not productive of serious consequences.
Case 9.— William C , aged thirty-three, was admitted ^ on
the 29th of September, 1866, under the care of Dr. Eben. V* at-
son, with a compound fracture of the left tibia, produced by an
62
Medical Classics
omnibus passing over the limb at eight o’clock P. M. The
broken part of the bone was exposed in a wound six and a half
inches in length, a little above the ankle. The skin in the vicin-
ity was detached from the subjacent tissues for about two inches,
and there was ecchymosis reaching some distance up the leg,
with other evidence of severe contusion.
(p. 508) An hour and a half after the accident Dr. A. Forsyth,
the house-surgeon, from whose notes these particulars are ob-
tained, sponged out the wound thoroughly with undiluted car-
bolic acid, and placed over it layers of calico soaked with the
acid; and, in order to provide for a sufficiently substantial crust,
spread over the calico some paste composed of starch moistened
with carbolic acid, covering the whole with a piece of block-
tin secured with a bandage, the fracture being treated with a
suitable apparatus. After the dressing, the patient, though
unable to express his feelings, being dumb, appeared entirely
free from uneasiness.
Next day the tin was carefully removed from the crust, the
surface of which was touched with carbolic acid, and, the tin
having been readjusted, hot fomentations were applied to the
leg and foot. The pulse was now 96, the tongue clean, and the
appetite good. The same treatment was pursued till the thir-
teenth day, when the fomentations were discontinued, and the
edges of the crust which were loose were clipped away, and lint
moistened with water was applied to the granulating surface
thus exposed, the remainder of the crust being still touched daily
with carbolic acid. Meanwhile there had been no suppuration
beneath the crust, and the patient had remained free from con-
stitutional symptoms.
On the seventeenth day the crust, which had separated from
the wound at its lower third, was removed, disclosing a healthy
granulating surface, the bone being nowhere visible, while there
was no appearance of pus, except a trifling amount towards the
lower part. The sore, which was entirely superficial, was now
treated like an ordinary ulcer, and healed quickly. The bone
also united as in a simple fracture, and he was discharged eight
Compound Fracture, Abscess 63
weeks after the receipt of the injury, having been kept longer
in the hospital than would otherwise have been necessary, on
account of a head affection to which he was subject.
The above case, besides being a good example of the effects
of the treatment of compound fracture with carbolic acid, affords
an illustration of a practice which I have on several occasions
found useful when there has been but little bleeding from the
wound, a dough or paste composed of flour or starch, moistened
with the acid, being employed in lieu of the compound with
blood to render the crust sufficiently substantial.
Case 10. — Thomas M’B , a labourer, who gave his age
as fifty-two, but had the appearance of a much older person,
was admitted at noon on the 2nd of January, 1867, under the
care of Dr. G. Buchanan, having been knocked down an hour
before by the shaft of a luggage wagon, the wheel of which passed
over his left leg, producing a compound fracture in the lower
third of the limb. Mr. James Robinson, the house-surgeon
who has given me notes of the case, found a wound from which
blood was oozing, about an inch and a half in length, exposing
part of the tibia, and communicating with the seat of fracture..
The tissues were pretty severely contused. Undiluted carbolic
acid was applied freely to the interior of the wound by means of
lint held in a pair of dressing forceps, and a crust was formed of
blood mingled with the acid, covered with lint, over which a cap
of tin was placed, well bulged out to correspond to the substantial
crust, and large enough to overlap to a slight extent the sound
skin in the vicinity. The fragments having been brought into
proper position, the limb was put up with lateral wooden splints,
with a hot fomentation. At the conclusion of the dressing the
patient expressed himself as greatly relieved. The pulse was
then 65.
Next day he was free from pain after a fair night s rest. The
pulse was 74, and the tongue clean and moist. The surface of
the crust was touched with carbolic acid, the limb being still
fomented; and the same treatment was continued daily for the
following fortnight, during which the limb was entirely free from
pain, redness, or suppuration, while his constitution was quite
Medical Classics
64
unaffected by the injury, the tongue remaining clean, and the
pulse varying only between 72 and 85.
I was present when the crust was removed, eighteen days
after the accident. Not a drop of pus existed beneath it. On
the contrary, the superficial sloughs of the cutis occasioned by
the caustic action of the acid first applied remained still unde-
tached. The exposed surface was treated with water-dressing,
and in two days presented the appearance of an ordinary granu-
lating sore, which healed without interruption. Six weeks and
three days after the receipt of the injury the splints were re-
moved, the bones being satisfactorily united.
This is an excellent example of the effects of the carbolic-
acid treatment in a compound fracture of the leg of average
severity. No simple fracture could have caused less disturbance,
either local or constitutional.
Case ii. — The following case, though incomplete, is given
on account of the conclusive evidence it affords regarding a
complication of compound fracture of much interest both prac-
tically and theoretically — viz., emphysema of the limb in conse-
quence of air being introduced into the wound, and diffused
among the interstices of the tissues by a pumping action of the
fragments of the broken bone when freely moved through rest-
lessness of the patient or carelessness of his attendants before
he comes under the surgeon’s care. Such a state of things may
seem at first sight to render it impossible to prevent decomposi-
tion of the extravasated blood, since it would be out of the ques-
tion to attempt to apply carbolic acid to all the emphysematous
tissues. But I have long indulged the hope that, the air enter-
ing in small successive portions, its floating organisms might be
arrested by the first blood with which they came in contact, and
remain for some time confined to the vicinity of the external
wound, in which case, by squeezing out as much blood as possible
from the orifice in the integument, and introducing carbolic
acid freely, we might get rid of all causes of decomposition in
the limb, the mere atmospheric gases diffused more remotely,
however abundant, being entirely innocuous. This hope, it now
appears, was not ill-founded.
John D , aged fifty-five, a calico-printer, of intemperate
Compound Fracture, Abscess 65
habits, was admitted under my care in the Royal Infirmary at
six P. M. on the 4th of April, 1867, having broken both bones
of his right leg about an hour before by jumping out of a window
into the street, from a height of between fifteen and twenty feet,
while in a state of intoxication. He was carried up-stairs to his
lodgings, kicking about in his drunken frenzy. A cloth was then
put round the leg, but no efficient means were employed to
steady it, and he was conveyed to the hospital from a distant
part of the city in a cab, moving the limb recklessly during the
whole journey. His friends stated that he had lost a great deal
of blood, and the cloth which was round the limb on his admis-
sion was saturated. Mr. H. Cameron, the house-surgeon, found
a wound about half an inch in length, situated over the spine of
the tibia, at the junction of the middle and lower thirds of the
bone, the fracture being half an inch lower down, and obviously
communicating. The wound was bleeding very freely, and the
leg was considerably swollen through extravasation of blood into
it. On manipulation, Mr. Cameron found the tissues about the
seat of fracture emphysematous, the characteristic crackling
sensation being experienced fully four inches above the wound
and two inches below it, and also on the opposite side of the limb,
over the fibula; and as a result of the handling, a frothy mixture
of blood and air, in larger and smaller bubbles, escaped from
the orifice. The fragments were much displaced, the foot being
greatly everted.
Mr. Cameron, having squeezed out as much blood as possible
from the wound, introduced melted crystallised carbolic acid in
a piece of calico held in dressing-forceps, which he passed in
various directions for more than two inches beneath the integu-
ment and about an inch and a half among the deeper structures
of the limb, using three different pieces of calico soaked with the
acid, and leaving the last in the wound as a plug to check the
very free hemorrhage, which the treatment had considerably in-
creased. He then applied several layers of calico steeped in
carolic acid and smeared with blood, so as to make, a pretty
thick crust overlapping the skin by about half an inch, and
adapted to the crust a cap of block-tin of slightly larger dimen-
sions, pressing it down upon the skin by means of a looped
66
Medical Classics
bandage encircling the leg. Having next corrected the displace-
ment of the fragments, he moulded a pasteboard splint to the
outer side of the leg and foot, strengthening it with a temporary
Gooch’s splint, and laid the limb on its outer side upon a pillow
with the knee bent. The patient now stated that the pain he
had suffered was greatly relieved. His pulse was loo. Two
hours later, as a good deal of oozing of blood was still going on,
a folded cloth was placed upon the tin cap and pressed down
upon it with a bandage. The limb meanwhile was considerably
more swollen, from bleeding into its interior, kept up, no doubt,
by the sudden jerking movements which in his unreasoning
condition he could not be prevented from making. The pressure
employed greatly diminished the external hemorrhage, but did
not entirely arrest it; and when two hours more had elapsed
Mr. Cameron asked my advice. I recommended the use of a
well-fitting internal splint, to procure greater steadiness of the
fragments, and so get rid of the irritation which perpetuated the
bleeding. Mr. Cameron, however, on removing the compress,
found that all tendency to oozing of blood had ceased. The pa-
tient was now sober, but continued very restless. The internal
splint was therefore applied, and thirty drops of solution of
muriate of morphia were administered.
(p. 509) During the night he suffered a good deal, and got no
sleep at all. Next morning, however, he complained rather of
a general sense of weariness and sickness, the consequences of
his debauch, than of pain; the pulse had fallen to 76; and he took
his breakfast pretty well. The surface of the crust was touched
with carbolic acid, and this was repeated in the afternoon, when
a hot fomentation was applied to the inner side of the leg, and
over this a sheet of stout block-tin, to serve, as in some previous
cases, the double purpose of ensuring the efficiency of the fomen-
tations, and acting as an internal splint. The limb was now
quite easy. At night the pulse was still 76. He had made a
pretty hearty supper, and felt only occasional twinges in the
limb. The fomentation was changed, and the crust again
touched with carbolic acid, and the opiate repeated.
He passed the following night like the preceding, without
getting any sleep whatever; and in the morning his pulse was 90,
Compound Fracture, Abscess 67
although the limb was free from pain or inflammatory blush ,
and he made a hearty breakfast. Fearing the approach of
traumatic delirium, I ordered a larger opiate to be given at
night. Fifty drops of the morphia solution were accordingly
administered; and after this dose he slept for about five hours.
Nevertheless, he grew more restless, and was found in the
morning with the leg fully extended and resting on the calf in-
stead of on its outer side. His pulse continued at 90; and
although the state of the limb and his appetite were all that
could be wished, he exhibited in the afternoon unmistakable
signs of delirium tremens, jerking out his tongue when asked to
show it, twitching his hands in an excited manner, and declaring
that his bedclothes were creeping away from him, while the rest-
less movements of the limb were continued. I ordered a dose of
castor oil, to be followed, as soon as it should have operated, by
a drachm of the solution of muriate of morphia, to be repeated
if necessary. He took the opiate about eight o’clock P. M., and
soon afterwards dozed a little; and at eleven his pulse had fallen
to 82. After this he fell into a sound sleep, from which he did
not wake until six A. M.; and from this time forth he was per-
fectly tranquil and rational.
It is needless to enter into particulars regarding his subsequent
progress further than to say that it has been in all respects
satisfactory; and on the tenth day after the accident, when I
saw him last, his pulse was 7 6, his appetite excellent, and he had
the appearance of a man in perfect health. The limb was still
free from pain, while the swelling due to extravasation of blood
had disappeared, and the skin was of natural aspect. After
the second day from the accident, there had not been even any
discharge of serum from beneath the crust, which had been daily
touched with carbolic acid, the fomentations being also con-
tinued, as he found them comfortable.
I need not hesitate to say that all danger in this case is over;
and that the compound fracture is already converted into a
simple one under circumstances which, even for a simple frac-
ture, would have been trying.
In revising the proof, after nine days more have elapsed.
I may add that all has continued to go on well.
PRELIMINARY NOTICE ON ABSCESS
YoL s, p. 95
In antidpation of the more detailed account which I hope will soon appear in
The Lancet, I will now give a description of a new method of treating abscess,
which has afforded results so satisfactory that it does not seem right to withhold it
longer from the profession generally, * ■
It is based, like the treatment of compound fracture,* on. the antiseptic principle,
and the material employed is essentially the same — namely, carbolic acid, but
differently applied in accordance with the difference of the tircum stances. In
compound fracture there is an irregular wound, which has probably been exposed to
the air for hours before it is seen by the surgeon, and may therefore contain in its
interstices the atmospheric germs which are the causes of decomposition, and those
must be destroyed by the energetic application of the antiseptic agent. In an
unopened abscess, on the other hand, as a general rule, no septic organisms are
present, so that it is not necessary to introduce the carbolic add into the interior.
Here the essential object is to guard against the introduction of living particles
from without, at the same time that a free exit is afforded for the constant discharge
of the contents. The mode in which this is accomplished is as follows: —
A solution of one part of crystallised carbolic add in four parts of boiled linseed
oil haring been prepared, a piece of rag from four to six inches square is dipped in
the oily mixture, and laid upon the skin where the indsion is to be made. The
lower edge of the rag bdng then raised, while the upper edge is kept from slipping
by an assistant, a common scalpel or bistoury dipped in the oil is plunged into the
cavity of the abscess, and an opening about three-quarters of an inch in length is
made, and the instant the knife is withdrawn the rag is dropped upon the skin as
an antiseptic curtain, beneath which the pus flows out into a vessel placed to reedve
it. The cavity of the abscess is firmly pressed, so as to force out all existing pus as
nearly as may be (the old fear of doing mischief by rough treatment of the pyogenic
membrane being quite ill-founded); and if there be much oozing of blood, or if there
be a considerable thickness of parts between the abscess and the surface, a piece
of lint dipped in the antiseptic oil is introduced into the incision to check bleeding
and prevent primary adhesion, which is otherwise very apt to occur. The intro-
duction of the lint is effected as rapidly as may be, and under the protection of the
antiseptic rag. Thus the evacuation of the original contents is accomplished with
perfect security against the introduction of living germs. This, however, would be
of no avail unless an antiseptic dressing could be applied that would effectually
prevent the decomposition of the stream of pus constantly flowing out beneath it.
.nfter numerous disappointments, I have succeeded with the following, which may
be relied upon as absolutely trustworthy. About six teaspoonfulls of the above-
mentioned solution of carbolic add in linseed oil are mixed up with common
whitening (carbonate of lime) to the consistence of a firm paste, which is in fact
glider s putty with the addition of a little carbolic add. This is spread upon a
prece of sheet block tin about six inches square; or common tinfoil will answer
equally well if strengthened with adhesive plaster to prevent it from tearing, and in
* See The Lancet of March 16th, 23rd, and 30th, and April 27th of the present
some situations it is preferable, from its adapting itself more readily to the shape
of the part affected. The putty forms a layer about a quarter of an inch thick;
it may be spread with a table-knife, or pressed out with the hand, a towel being
temporarily interposed to prevent the putty from sticking to the hand or soiling
the coat-sleeve. The tin thus spread with putty is placed upon the skin so that
the middle of it corresponds to the position of the incision, the antiseptic rag used
in opening the abscess being removed the instant before. The tin is then fixed
securely by adhesive plaster, the lowest edge being left free for the escape of the
discharge into a folded towel placed over it and secured by a bandage. This
dressing has the following advantages; . . . The tin prevents the evaporation of
the carbolic acid, which escapes readily through any organic tissue such as oiled
silk or guttapercha. The putty contains the carbolic add just suffidently diluted
to prevent its excoriating the skin, while its substance serves as a reservoir of the
add during the intervals between the dressings. Its oily nature and tenadty
prevent it from being washed away by the discharge, which all oozes out beneath
it as fast as it escapes from the incision; while the extent of the surface of the
putty renders it securely antiseptic. Lastly, the putty is a deanly application,
and gives the surgeon very little trouble; a supply being daily made by some
convalescent in an hospital, or in private practice by the nurse or a friend of the
patient; or a larger quantity may be made at once, and kept in a tin canister. The
dressing is changed, as a general rule, once in twenty-four hours; but if the abscess
be a very large one, it is prudent to see the patient twelve hours after it has been
opened, when, if the towel should be much stained with discharge, the dressing
should be changed, to avoid subjecting its antiseptic virtues to too severe a test.
But after the first twenty-four hours, a single daily dressing is sufficient. The
changing of the dressing must be methodically done, as follows: — A second similar
piece of tin having been spread with the putty, a piece of rag is dipped in the oily
solution, and placed on the incision the moment the first tin is removed. This
guards against the possibility of mischief occurring during the cleansing of the
skin with a dry cloth and pressing out any discharge which may exist in the cavity.
If a plug of lint was introduced when the abscess was opened, it is removed under
cover of the antiseptic rag, which is taken off at the moment when the new tin is
to be applied. The same process is continued daily till the sinus closes.
The results of this treatment are such as correct pathological knowledge might
have enabled us to predict. The pyogenic membrane has no innate disposition to
form pus, but does so only because it is subjected to some preternatural stimulus.
In an ordinary abscess, whether acute or chronic, the original cause that led to
suppuration is no longer in operation, and the stimulus that determines the con-
tinued pus formation is derived from the presence of the pus pent up in the interior.
When an abscess is opened in the ordinary way this cause of stimulation is removed,
but in its place is substituted the potent stimulus of decomposition. If, however,
the abscess be opened antisepticaily, the pyogenic membrane, freed from the
operation of the previous stimulus without the substitution of a new one, ought,
according to theory, to cease to suppurate, while the patient should be relieved from
any local or general disturbance caused by the abscess, without the risk of irritative
fever or hectic. . . .
Such, accordingly, is the fact. Abscesses of large size have, after the original
contents have been evacuated, furnished no further pus whatever, the discharge
being merely serum, which in a few days has amounted only to a few drops in the
twenty-four hours. Whether the opening be dependent or not is a matter of
perfect indifference, the small amount of unirritating fluid being all evacuated
spontaneously by the rapidly contracting pyogenic membrane. At the same time,
we reckon with perfect certainty on the absence of all constitutional disturbance.
As an illustration, I may mention the last case which has come under my care.
Itisthatofa young woman, twenty-five years old, with psoas abscess, which had
of late been rapidly on the increase, and caused a large swelling below Poupart’s
ligament, communicating with a fluctuating mass, dull on percussion, reaching to
a considerable distance up the abdomen, the femoral vessels being raised over the
communication between them. Six days ago I opened, in the manner above
described, the swelling in the thigh at the anterior part of the limb where it was
nearest the surface, giving exit to twenty-seven ounces of pus, thin, but containing
numerous large curdy masses. I introduced a piece of lint, dipped in the carbolic
add and oil, into the indsion; and this prevented any discharge from escaping
during the next twenty-four hours, (p. 96), when, on removal of the plug of lint
under an antiseptic rag, three ounces of turbid serum escaped. For the next three
days there was scarcely any discharge, the deeper parts of the indsion having
cohered. On firm pressure, however, the product of seventy-two hours escaped,
and amounted to four drachms of serum. Meanwhile the girl’s general health,
which had not been interfered with by the abscess, continued perfectly good,
ndther pulse, tongue, appetite, nor sleep having been disturbed.
In this case, though there is no deformity of the spine, there is great probability
that caries of the vertebrae is present. But even though such be the case, there is
good reason to hope for a favourable issue. Regarding caries as merely the sup-
purative stage of chronic inflammation in a weak form of tissue, I have been not
surprised, though greatly rejoiced, to find that it exhibits the tendency of inflam-
matory affections generally — viz., a disposition to spontaneous cure on the with-
drawal of irritation. Hitherto, in surgical practice, caries has had to contend
against the formidable irritation of decomposing matter, which, under circum-
stances of weakness, is often sufficient to cause ulceration, even in the soft parts;
yet, in spite of this irritation, canes is often recoverable in the child where the vital
powers of all the tissues are stronger. If, therefore, this serious complication can
be avoided, there seems nothing in theory against the probability that caries
may prove curable in the adult. And even should portions of necrosed bone be
present, as is not unfrequently the case, our experience of the treatment of com-
pound fracture with carbolic add has taught us that dead bone, if undecomposcd,
nor only fails to induce suppuration in its vidnity, but is liable to absorption by the
granulations around it.*
Such were the hopes which I ventured to express several months ago to my winter
cms. Since that time I have opened numerous abscesses connected with caries
o the * er^ebrae, the hip, knee, ankle, and elbow, and in all cases I have found the
tscharge become in a few days trifling in amount, and in many it has ceased to be
punform after the first twenty-four hours. Finally, three days ago— viz., on the
4th ms, (July, 1S67), I had the inexpressible happiness of finding the sinus
soun.w y dosed in a middle-aged man, in whom I opened in February last a psoas
Sre The Lancet of March 23rd, p. 359.
abscess, proved to be connected with diseased bone by the discharge, on one
occasion, of an osseous spiculum. For months past we had persevered with the
antiseptic dressing, although the discharge did not amount to more than a drop or
two of serum in the twenty-four hours, well knowing by bitter experience that so
Jong as a sinus existed the occurrence of decomposition might produce the most
disastrous consequences; and at length our patience has been crowned with success.
Hence I no longer feel any hesitation in recommending the early opening of such
abscesses, because, while they remain unopened, the disease of the bone is neces-
sarily progressive, whereas when opened antisepticaUy, there is good ground to
hope for their steady, though tedious, recovery.
The putty of the strength above recommended, though it generally fails to ex-
coriate the skin, sometimes produces this effect when long continued. In such
case it may be reduced in strength so that the oil contains only one part to five or
six without disadvantage when the discharge is very small in amount.
The application prevents the occurrence of cicatrisation in the little sore caused
by the incision, and perpetuates a trifling discharge from it. Hence it is impossible
to judge whether or not the sinus has dosed, except by examining it from time to
time with a probe, which should be dipped in the antiseptic oil, and passed in
between folds of the antiseptic rag. This may seem a refinement, but if we could
see with the naked eye a few only of the septic organisms that people every cubic
inch of the atmosphere of an hospital ward, we should rather wonder that the
antiseptic treatment is ever successful than omit any precautions in conducting it.
The putty used in treating abscesses has proved very valuable in simplifying
the treatment of compound fracture, and enlarging the range of its applicability,
and also in dealing with incised wounds on the antiseptic principle. But I must
defer a notice of these matters to a future occasion.
Glasgow, July, 1867.
On the Antiseptic Principle in the
Practice of Surgery*
BY
JOSEPH LISTER, Esq., F.R.S.
Professor cf Surgery in the University Of Glasgow
Published in The Lancet, 2: 353~35 6, 1867
£N THE course of an extended investigation into
the nature of inflammation, and the healthy
r^, and morbid conditions of the blood in relation
t0 ^ arrived, several years ago, at the con-
' A£L ' fj? elusion that the essential cause of suppuration
g in wounds is decomposition, brought about
by the influence of the atmosphere upon blood or serum retained
within them, and, in the case of contused wounds, upon portions
of tissue destroyed by the violence of injury.
To prevent the occurrence of suppuration, with all its at-
tendant risks, was an object manifestly desirable; but till lately
apparently unattainable, since it seemed hopeless to attempt to
exclude the oxygen, which was universally regarded as the agent
by which putrefaction was effected. But when it had been
shown by the researches of Pasteur that the septic property of
the atmosphere depended, not on the oxygen or any gasous
constituent, but on minute organisms suspended in it, which
owed their energy to their vitality, it occurred to me that decom-
position in the injured part might be avoided without excluding
the air, by applying as a dressing some material capable of
destroying the life of the floating particles.
■"* P“P^* before the British Medical Association in Dublin on the 9th of August)
lift
Antisepsis in Surgery 73
Upon this principle I have based a practice of which I will
now attempt to give a short account.
The material which I have employed is carbolic or phcnic
acid, a volatile organic compound which appears to exercise a
peculiarly destructive influence upon low forms of life, and
and hence is the most powerful antiseptic with which we are at
present acquainted.
7 he first class of eases to which I applied it was that of com-
pound fractures, in which the effects of decomposition in the
injured part were especially striking and pernicious. The results
might have been such as to establish conclusively the Great
principle, that cl! the leer.! inflammatory mischief and general
febrile disturbance 'c hid: folia:? severe injuries are due to the irri-
tating and poisoning influence cf decomposing blood cr sloughs.
I' or these evils arc entirely avoided by the antiseptic treatment,
so that limbs which otherwise would be unhesitatingly con-
demned to amputation may be retained with confidence of the
best results.
In conducting the treatment, the first object must be the
destruction of any septic germs which may have been intro-
duced into the wound, either at the moment of the accident or
during tiic time which has since elapsed. This is done by in-
troducing the acid of full strength into all accessible recesses of
the wound by means of a piece of rag held in dressing forceps
and dipped in the liquid.* This I did not venture to do in the
earlier eases; but experience lias shown that the compound which
carbolic acid forms with the blood, and also any portions of tissue
killed by its caustic action, including even parts of the bone,
arc disposed of by absorption and organisation, provided they are
afterwards kept from decomposing. We arc thus enabled to
employ the antiseptic treatment efficiently at a period after the
occurrence of the injury at which it would otherwise probably
fail. Thus I have now under my care in the Glasgow Infirmary
a boy who was admitted with compound fracture of the leg as
late as eight and a half hours after the accident, in whom never-
* The addition of a few drops of water to a considerable quantity of the crystallised
acid induces it to assume permanently the liquid form.
Medical Classics
74
theless all local and constitutional disturbance was avoided by-
means of carbolic acid, and the bones were firmly united five
weeks after his admission.
The next object to be kept in view is to guard effectually
against the spreading of decomposition into the wound along
(p. 354) the stream of blood and serum which oozes out during
the first few days after the accident, when the acid originally
applied has been washed out, or dissipated by absorption and
evaporation. This part of the treatment has been greatly
improved during the last few weeks. The method which I
have hitherto published* consisted in the application of a piece
of lint dipped in the acid, overlapping the sound skin to some
extent, and covered with a tin cap, which was daily raised in
order to touch the surface of the lint with the antiseptic. This
method certainly succeeded well with wounds of moderate size;
and, indeed, I may say that in all the many cases of this kind
which have been so treated by myself or my house-surgeons, not
a single failure has occurred. ’When, however, the wound is
very large, the flow of blood and serum is so profuse, especially
during the first twenty-four hours, that the antiseptic application
cannot prevent the spread of decomposition into the interior
unless it overlaps the sound skin for a very considerable distance,
and this was inadmissible by the method described above, on
account of the extensive sloughing of the surface of the cutis
which it would involve. This difficulty has, however, been
overcome by employing a paste composed of common whitening
(carbonate of lime) mixed with a solution of one part of carbolic
acid in four parts of boiled linseed oil, so as to form a firm putty.
This application contains the acid in too dilute a form to excori-
ate the skin, which it may be made to cover to any extent that
may be thought desirable, while its substance serves as a reser-
voir of the antiseptic material. So long as any discharge con-
tinues, the paste should be changed daily; and, in order to
prevent the chance of mischief occurring during the process,
a piece of rag dipped in the solution of carbolic acid in oil is put
on next the skin, and maintained there permanently, care being
* Tt- 1 Lmc** for March 1 6th, 23rd, and 33th, and April 27th, of the present year.
Antisepsis in Surgery 7 5
taken to avoid raising it along with the putty. This rag is al-
ways kept in an antiseptic condition from contact with the paste
above it, and destroys any germs that may fall upon it during
the short time that should alone be allowed to pass in the chang-
ing of the dressing. The putty should be in a layer about a
quarter of an inch thick, and may be advantageously applied
rolled out between two pieces of calico, which maintain it in the
form of a continuous sheet, that may be wrapped in a moment
round the whole circumference of a limb, if this be thought de-
sirable, while the putty is prevented by the calico from sticking
to the rag which is next the skin.* When all discharge has
ceased, the use of the paste is discontinued, but the original
rag is left adhering to the skin till healing by scabbing is sup-
posed to be complete. I have at present in the hospital a man
with severe compound fracture of both bones of the left leg,
caused by direct violence, who, after the cessation of the sanious
discharge under the use of the paste, without a drop of pus
appearing, has been treated for the last two weeks exactly as
if the fracture were a simple one. During this time the rag,
adhering by means of a crust of inspissated blood collected
beneath it, has continued perfectly dry, and it will be left un-
touched till the usual period for removing the splints in a simple
fracture, when we may fairly expect to find a sound cicatrix
beneath it.
We cannot, however, always calculate on so perfect a result
as this. More or less pus may appear after the lapse of the first
week; and the larger the wound the more likely is this to happen.
And here I would desire earnestly to enforce the necessity of
persevering with the antiseptic application, in spite of the ap-
pearance of suppuration, so long as other symptoms are favour-
able. The surgeon is extremely apt to suppose that any sup-
puration is an indication that the antiseptic treatment has
failed, and that poulticing or water-dressing should be resorted
* In order to prevent evaporation of the add, which passes readily through any organic
tissue, such as oiled silk or gutta percha, it is well to cover the paste with a sheet of block
tin, or tinfoil strengthened with adhesive plaster. The thin sheet-lead used or mng
tea-chests will also answer the purpose, and may be obtained from any wholesale grocer.
Medical Classics
76
to. But such a course would in many cases sacrifice a limb or
a life. I cannot, however, expect my professional brethren to
follow my advice blindly in such a matter, and therefore I feel
it necessary to place before them, as shortly as I can, some
pathological principles, intimately connected not only with the
point we are immediately considering, but with the whole sub-
ject of this paper.
If a perfectly healthy granulating sore be well washed and
covered with a plate of clean metal, such as block tin, fitting
its surface pretty accurately, and overlapping the surrounding
skin an inch or so in every direction, and retained in position
by adhesive plaster and a bandage, it will be found, on removing
it after twenty-four or forty-eight hours, that little or nothing
that can be called pus is present^ merely a little transparent
fluid, while at the same time there is an entire absence of the
unpleasant odour invariably perceived when water-dressing is
changed. Here the dean metallic surface presenting no recesses,
like those of porous lint, for the septic germs to develop in, the
fluid exuding from the surface of the granulations has flowed
away un decomposed, and the result is absence of suppuration.
This simple experiment illustrates the important fact, that
granulations have no inherent tendency to form pus, but do so
only when subjected to a preternatural stimulus. Further, it
shows that the mere contact of a foreign body does not of itself
stimulate granulations to suppurate; whereas the presence of
decomposing organic matter does. These truths are even more
strikingly exemplified by the fact, which I have elsewhere re-
corded,* that a piece of dead bone, free from decomposition, may
not only fail to induce the granulations around it to suppurate,
but may actually be absorbed by them; whereas a bit of dead
bone soaked with putrid pus infallibly induces suppuration in
its vicinity.
Another instructive experiment is to dress a granulating sore
with some of the putty above described, overlapping the sound
skin extensively, when we find in the course of twenty-four
* St: Tfc: Lzzctt, Mzrch 23rd, 1E67.
Antisepsis in Surgery 77
hours that pus has been produced by the sore, although the ap-
plication has been perfectly antiseptic; and, indeed, the larger
the amount of carbolic acid in the paste the greater is the quan-
tity of pus formed, provided we avoid such a proportion as would
act as a caustic. The carbolic acid, though it prevents decompo-
sition, induces suppuration— obviously by acting as a chemical
stimulus; and we may safely infer that putrescent organic ma-
terials (which we know to be chemically acrid) operate in the
same way.
In so far, then, carbolic acid and decomposing substances
are alike — namely, that they induce suppuration by chemical
stimulation, as distinguished from what may be termed simple
inflammatory suppuration, such as that in which ordinary ab-
scesses originate, where the pus appears to be formed in conse-
quence of an excited action of the nerves, independently of any
other stimulus. There is, however, this enormous difference
between the effects of carbolic acid and those of decomposition —
viz., that carbolic acid stimulates only the surface to which it
is first applied, and every drop of discharge that forms weakens
the stimulant by diluting it. But decomposition is a self-
propagating and self-aggravating poison; and if it occurs at the
surface of a severely injured limb, it will spread into all its re-
cesses so far as any extravasated blood or shreds of dead tissue
may extend, and, lying in these recesses, it will become from hour
to hour more acrid till it acquires the energy of a caustic, suffi-
cient to destroy the vitality of any tissues naturally weak from
inferior vascular supply, or weakened by the injury they sus-
tained in the accident.
Hence it is easy to understand how, when a wound is very
large, the crust beneath the rag may prove here and there
insufficient to protect the raw surface from the stimulating
influence of the carbolic acid in the putty, and the result will
be, first, the conversion of the tissues so acted on into granula-
tions, and subsequently the formation of more or less pus. This,
however, will be merely superficial, and will not interfere with
the absorption and organisation of extravasated blood or dead
tissues in the interior; but, on the other hand, should decomposi-
Medical Classics
78
tion set in before the internal parts have become securely con-
solidated, the most disastrous results may ensue.
I left behind me in Glasgow a boy, thirteen years of age,
who between three and four weeks previously met with a most
severe injury to the left arm, which he got entangled in a machine
at a fair. There was a wound six inches long and three inches
broad, and the skin was very extensively undermined beyond its
limits, while the soft parts generally were so much lacerated that
a pair of dressing forceps introduced at the wound, and pushed
directly inwards, appeared beneath the skin at the opposite
aspect of the limb. From this wound several tags of muscle
were hanging, and among them there was one consisting of about
three inches of the triceps in almost its entire thickness; while
the lower fragment of the bone, which was broken high up,
was protruding four and a half inches, stripped of muscle, the
skin being tucked in under it. Without the assistance. of the
antiseptic treatment, I should certainly have thought of nothing
else but amputation at the shoulder-joint; but as the radial
pulse could be felt, and the fingers had sensation, I did not hesi-
tate to try to save the limb, and adopted the plan of treatment
above described, wrapping the arm from the shoulder to below
the elbow in the antiseptic application, the whole interior of
the wound, together with the protruding bone, having previ-
ously been freely treated (p. 355) with strong carbolic acid.
About the tenth day the discharge, which up to that time had
been only sanious and serous, showed a slight admixture of slimy
pus, and this increased till, a few days before I left, it amounted
to about three drachms in twenty-four hours. But the boy
continued, as he had been after the second day, free from un-
favourable symptoms, with pulse, tongue, appetite, and sleep
natural, and strength increasing, while the limb remained, as
it had been from the first, free from swelling, redness, or pain.
I therefore persevered with the antiseptic dressing, and before
I left, the discharge was already somewhat less, while the bone
was becoming firm. I think it likely that in that boy’s case I
should have found merely a superficial sore had I taken off all
the dressings at the end of three weeks, though, considering the
Antisepsis in Surgery 79
extent of the injury, I thought it prudent to let the month ex-
pire before disturbing the rag next to the skin. But I feel sure
that if I had resorted to ordinary dressing when the pus first
appeared, the progress of the case would have been exceedingly
different.
The next class of cases to which I have applied the antiseptic
treatment is that of abscesses. Here, also, the results have
been extremely satisfactory, and in beautiful harmony with the
pathological principles indicated above. The pyogenic mem-
brane, like the granulations of a sore, which it resembles in na-
ture, forms pus, not from any inherent disposition to do so,
but only because it is subjected to some preternatural stimula-
tion. In an ordinary abscess, whether acute or chronic, before
it is opened, the stimulus which maintains the suppuration is
derived from the presence of the pus pent up within the cavity.
When a free opening is made in the ordinary way, this stimulus
is got rid of; but the atmosphere gaining access to the contents,
the potent stimulus of decomposition comes into operation, and
pus is generated in greater abundance than before. But when
the evacuation is effected on the antiseptic principle, the pyo-
genic membrane, freed from the influence of the former stimulus
without the substitution of a new one, ceases to suppurate (like
the granulations of a sore under metallic dressing), furnishing
merely a trifling amount of clear serum, and, whether the open-
ing be dependent or not, rapidly contracts and coalesces. At
the same time any constitutional symptoms previously occa-
sioned by the accumulation of the matter are got rid of without
the slightest risk of the irritative fever or hectic hitherto so
justly dreaded in dealing with large abscesses.
In order that the treatment may be satisfactory, the abscess
must be seen before it has opened. Then, except in very rare
and peculiar cases,* there are no septic organisms in the con-
tents, so that it is needless to introduce carbolic acid into the
* As an instance of one of these exceptional cases, I may mention that of an abscess
in the vicinity of the colon, and afterwards proved by post-mortem examination to have
once communicated with it. Here the pus was extremely offensive when evacuated, and
exhibited vibrios under the microscope.
8o
Medical Classics
interior. Indeed, such a proceeding would be objectionable, as
it would stimulate the pyogenic membrane to unnecessary sup-
puration. All that is necessary is to guard against the intro-
duction of living atmospheric germs from without, at the same
time that free opportunity is afforded for the escape of discharge
from within.
I have so lately given elsewhere* a detailed account of the
method by which this is effected, that it is needless for me to
enter into it at present, further than to say that the means
employed are the same as those described above for the superfi-
cial dressing of compound fractures — namely, a piece of rag
dipped in the solution of carbolic acid in oil, to serve as an anti-
septic curtain, under cover of which the abscess is evacuated by
free incision; and the antiseptic paste, to guard against decompo-
sition occurring in the stream of pus that flows out beneath it:
the dressing being changed daily till the sinus has closed.
The most remarkable results of this practice in a pathological
point of view have been afforded by cases where the formation
of pus depended upon disease of bone. Here the abscesses,
instead of forming exceptions to the general class in the obstinacy
of the suppuration, have resembled the rest in yielding in a few
days only a trifling discharge; and frequently the production
of pus has ceased from the moment of the evacuation of the origi-
nal contents. Hence it appears that caries, when no longer
labouring, as heretofore, under the irritation of decomposing
matter, ceases to be an opprobrium of surgery, and recovers like
other inflammatory affections. In the publication before al-
luded toy 1 have mentioned the case of a middle-aged man with
psoas abscess depending on diseased bone, in whom the sinus
finally closed after months of patient perseverance with the
antiseptic treatment. Since that article was written, I have
had another instance of success, equally gratifying, but differing
in the circumstance that the disease and the recovery were both
more rapid in their course. The patient was a blacksmith who
had suffered four and a half months before I saw him from
* Sec The Lancet of July 27 th, 1E67.
t Ibid*
Antisepsis in Surgery 8 1
symptoms of ulceration of cartilage in the left elbow. These
had latterly increased in severity, so as to deprive him entirely
of his night’s rest and of appetite. I found the region of the
elbow greatly swollen, and on careful examination discovered a
fluctuating point at the outer aspect of the articulation. I
opened it on the antiseptic principle, the incision evidently
penetrating to the joint, giving exit to a few drachms of pus.
The medical gentleman under whose care he was (Dr. Mac-
gregor of Glasgow) supervised the daily dressing with the car-
bolic-acid paste till the patient went to spend two or three weeks
at the coast, when his wife was entrusted with it. Just two
months after I opened the abscess he called to show me the limb,
stating that the discharge had for at least two weeks been as
little as it then was — a trifling moisture upon the paste, such as
migh be accounted for by the little sore caused by the incision.
On applying a probe guarded with an antiseptic rag, I found that
the sinus was soundly closed, while the limb was free from swell-
ing or tenderness; and, although he had not attempted to exer-
cise it much, the joint could already be moved through a con-
siderable angle. Here the antiseptic principle had effected the
restoration of a joint which on any other known system of treat-
ment must have been excised.
Ordinary contused wounds are of course amenable to the
same treatment as compound fractures, which are a complicated
variety of them. I will content myself with mentioning a single
instance of this class of cases. In April last a volunteer was dis-
charging a rifle, when it burst, and blew back the thumb with
its metacarpal bone, so that it could be bent back as on a hinge
at the trapezial joint, which had evidently been opened, while
all the soft parts between the metacarpal bones of the thumb
and forefinger were torn through. I need not insist before my
present audience on the ugly character of such an injury. My
house-surgeon, Mr. Hector Cameron, applied carbolic acid to
the whole raw surface, and completed the dressing as if for com-
pound fracture. The hand remained free from pain, redness,
or swelling, and, with the exception of a shallow groove, all
the wound consolidated without a drop of matter, so that if it
82
Medical Classics
had been a clean cut, it would have been regarded as a good
example of primary union. The small granulating surface soon
healed, and at present a linear cicatrix alone tells of the injury
he sustained, while his thumb has all its movements and his
hand a firm grasp.
If the severest form of contused and lacerated wounds heal
thus kindly under the antiseptic treatment, it is obvious that
its application to simple incised wounds must be merely a matter
of detail. I have devoted a good deal of attention to this class,
but I have not as yet pleased myself altogether with any of the
methods I have employed. I am, however, prepared to go so
far as to say that a solution of carbolic acid in twenty parts of
water, while a mild and cleanly application, may be relied on
for destroying any septic germs that may fall upon the wound
during the performance of an operation; and also that for pre-
venting the subsequent introduction of others, the paste above
described, applied as- for compound fractures, gives excellent
results. Thus I have had a case of strangulated inguinal hernia,
in which it was necessary to take away half a pound of thickened
omentum, heal without any deep-seated suppuration or any ten-
derness of the sac or any fever; and amputations, including one
immediately below the knee, have remained absolutely free
from constitutional symptoms.
Further, I have found that when the antiseptic treatment is
efficiently conducted, ligatures may be safely cut short and
left to be disposed of by absorption or otherwise. Should this
particular branch of the subject yield all that it promises, should
it turn out on further trial that when the knot is applied on the
antiseptic principle, we may calculate as securely as if it were
absent on the occurrence of healing without any deep-seated
suppuration; the deligation of main arteries in their continuity
will be deprived of the two dangers that now attend it — viz.,
those of secondary hemorrhage and an unhealthy state of the
wound. Further, it seems not unlikely that the present objec-
tion to tying an artery in the immediate vicinity of a large
branch may be done away with; and that even the innominate,
which has lately been the subject of an ingenious experiment by
Antisepsis in Surgery 83
one of the Dublin surgeons on account of its well-known fatality-
under the ligature from secondary hemorrhage, may cease to
have this unhappy character, when the tissues in the vicinity
of the thread, instead of becoming softened through the influ-
ence of an irritating decomposing (p. 356) substance, are left at
liberty to consolidate firmly near an unoffending though foreign
body.
It would carry me far beyond the limited time which, by the
rules of the Association, is alone at my disposal, were I to enter
into the various applications of the antiseptic principle in the
several special departments of surgery.
There is, however, one point more that I cannot but advert
to — namely, the influence of this mode of treatment upon the
general healthiness of a hospital. Previously to its introduction,
the two large wards in which most of my cases of accident and
of operation are treated were amongst the unhealthiest in the
whole surgical division of the Glasgow Royal Infirmary, in con-
sequence, apparently, of these wards being unfavourably placed
with reference to the supply of fresh air; and I have felt
ashamed, when recording the results of my practice, to have so
often to allude to hospital gangrene or pyaemia. It was in-
teresting, though melancholy, to observe that, whenever all, or
nearly all, the beds contained cases with open sores, these
grievous complications were pretty sure to show themselves; so
that I came to welcome simple fractures, though in themselves
of little interest either for myself or the students, because their
presence diminished the proportion of open sores among the
patients. But since the antiseptic treatment has been brought
into full operation, and wounds and abscesses no longer poison
the atmosphere with putrid exhalations, my wards, though in
other respects under precisely the same circumstances as before,
have completely changed their character; so that during the
last nine months not a single instance of pyaemia, hospital
gangrene, or erysipelas has occurred in them.
As there appears to be no doubt regarding the cause of this
change, the importance of the fact can hardly be exaggerated.
THE END
On the Effects of the Antiseptic
System of Treatment upon the
Salubrity of a Surgical Hospital
BY
JOSEPH LISTER, F.R.S.
Professor af Clinical Surgery in the University cf Edinburgh
London Lancet, is 194-2.CO, 1870
IE antiseptic system of treatment has now been
in operation sufficiently long to enable us to
form a fair estimate of its influence upon the
salubrity of an hospital.
Its effects upon the wards lately under my
care in the Glasgow Royal Infirmary were in
the highest degree beneficial, converting them from some of the
most unhealthy in the kingdom into models of healthiness. The
interests of the public demand that this striking change should be
made generally known; and in order to do justice to the subject,
it is necessary, in the first place, to allude shortly to the position
and circumstances of the wards.
Each of the four surgeons of the infirmary had charge of three
large wards, two male and one female, besides several small ones
for special cases. Of these, the most important were the male
accident ward and that for female patients, the former containing
the chief operation cases as well as those of injury. The third
main ward of each surgeon was devoted to chronic male cases,
and was in the old infirmary building; but the other two were in
the “New Surgical Hospital,” erected nine years ago. This
s 4
Antisepsis and Surgical Hospital
consists of four stories above a basement, each floor containing
two large wards communicating with a central staircase, besides
several smaller apartments. The wards are spacious and loft}',
and in the centre of each are two open fireplaces, in a column
which runs straight up to the roof, conveying the chimneys of
all the floors, and also collateral ventilating shafts, which are
warmed by the chimneys that accompany them, and, communi-
cating with various apertures in the ceilings, form excellent means
of carrying off the vitiated atmosphere, while fresh air is amply
supplied by numerous windows at both sides, the beds being
placed in the intervals between them, at a considerable distance
from each other. Except the serious defect that the water-
closets in many cases open directly into the wards, the system of
construction seemed all that could be desired.
But, to the great disappointment of all concerned, this noble
structure proved extremely unhealthy. Pyaemia, erysipelas, and
hospital gangrene soon showed themselves, affecting, on the
average, most severely those parts of the building nearest to the
ground,* including my male accident ward, which was one of
those on the ground-floor; while my female ward was on the floor
immediately above. For several years I had the opportunity of
making an observation of considerable, though melancholy,
interest — viz., that in my accident ward, when all or nearly all
the beds contained patients with open sores, the diseases which
result from hospital atmosphere were sure to be present in an
aggravated form; whereas, when a large proportion of the cases
had no external wound, the evils in question were greatly miti-
. gated or entirely absent. This appeared striking evidence that
the emanations from foul discharges, as distinguished from the
mere congregation of several human beings in the same apart-
ment, constitute the great source of mischief in a surgical hospital.
Hence I came to regard simple fractures, though almost destitute
of professional interest to myself, and of little value for clinical
instruction, as the greatest blessings; because, having no external
* Statistics collected by desire of the managers established the fact that the ground-
floor wards were, on the average, most liable to pytemia, whoever might be the surgeon
in charge; and that those on the floor immediately above came next in this respect.
86
Medical Classics
wound, they diminished the proportion of contaminating cases.
At this period I was engaged in a perpetual contest with the
managing body, who, anxious to provide hospital accommodation
for the increasing population of Glasgow, for which the infirmary
was by no means adequate, were disposed to introduce additional
beds beyond those contemplated in the original construction.
It is, I believe, fairly attributable to the firmness of my resistance
in this matter that, though my patients suffered from the evils
alluded to in a way that was sickening and often heart-rending,
so as to make me sometimes feel it a questionable privilege to be
connected with the institution, yet none of my wards ever
assumed the frightful condition which sometimes showed itself
in other parts of the building, making it necessary to shut them
up entirely for a time. A crisis of this kind occurred rather more
than two years ago in the other male accident ward on the
ground-floor, separated from mine merely by a passage 12. ft.
broad; where the mortality became so excessive as to lead, not
only to closing the ward, but to an investigation into the cause
of the evil, which was presumed to be some foul drain. An exca-
vation made with this view disclosed a state of things which
seemed to explain sufficiently the unhealthiness that had so long
remained a mystery. A few inches below the surface of the
ground, on a level with the floors of the two lowest male accident
wards, with only the basement area, 4 ft. wide, intervening, was
found the uppermost tier of a multitude of coffins, which had
been placed there at the time of the cholera epidemic of 1849,
the corpses having undergone so little change in the interval
that the clothes they had on at the time of their hurried burial
were plainly distinguishable. The wonder now was, not that
these wards upon the ground-floor had been unhealthy, but that
they had not been absolutely pestilential. Yet at the very time
when this shocking disclosure was being made, I was able to
state in an address which I delivered to the meeting of the British
Medical Association in Dublin, that during the previous nine
months, in which the antiseptic system had been fairly in opera-
tion in my wards, not a single case of pyemia, erysipelas, or
hospital gangrene had occurred in them; and this, be it remem-
Antisepsis and Surgical Hospital 87
bered, not only in the presence of conditions likely to be
pernicious, but at a time when the unhealthiness of other parts
of the same building was attracting the serious and anxious
attention of the managers. Supposing it justifiable to institute
an experiment on such a subject, it would be hardly possible to
devise one more conclusive.
Having discovered this monstrous evil, the managers at once
did all in their power to correct it. The extent of the corrupting
mass was so great that it seemed out of the question to attempt
its removal; but it was freely treated with carbolic acid and with
quick lime, and an additional thickness of earth was laid over it;
and, further, a high wall at right angles with the end of the
building, and reaching up to the level of the first floor, so as
necessarily to confine the bad air most prejudicially, was pulled
down, and an open iron railing was substituted for it.
There can be no doubt that these measures must have proved
salutary. But even if it were admitted that they cured com-
pletely the particular evil against which they were directed, it
would still have to be confessed that the situation of the surgical
hospital has been far from satisfactory. Besides having along
one of its sides the place of sepulture above alluded to, one end
of the building is conterminous with the old Cathedral church-
yard, which is of large size and much used, and in which the
system of “pit burial” of paupers has hitherto prevailed. I saw
one of the pits some time since, having been requested to report
upon it by one of the civic authorities, who is also a manager of
the infirmary, and who, having accidentally discovered what was
going on, at once took steps to prevent for the future the occur-
rence of anything so disgraceful. The pit, which was standing
open for the reception of the next corpse, emitted a horrid stench
on the removal of some loose boards from its mouth. Its walls
were formed, on three sides, of coffins piled one upon another
in four tiers with the lateral interstices between them filled with
human bones, the coffins reaching up to within a few inches of
the surface of the ground. This was in a place immediately
adjoining the patients’ airing ground, and a few yards only from
the windows of the surgical wards. And the pit which I inspected
88
Medical Classics
seems to have been only one of many similar receptacles, for one
of the Glasgow newspapers contains a statement that “the Dean
of Guild is said to have computed that five thousand bodies
were lying in pits, holding eighty each, in a state of decomposi-
tion, around the Infirmary.”* * * § Just beyond the churchyard rises
an eminence covered by an extensive necropolis, which, however,
from its greater distance, must have comparatively little dele-
terious influence. When I add that what is called the fever
hospitalj also a long four-storied building, extends at right
angles to the new surgical hospital, separated from it by only
eight feet, and that the entire infirmary, containing 584 beds,
stands upon an area of two acres, and that the institution is
almost always full to overflowing,! I have said enough to show
that the wards at my disposal have been sufficiently trying for
any system of surgical treatment. Yet, during the two years and
a quarter that elapsed between the Dublin meeting and the time
of my leaving Glasgow for Edinburgh, those wards continued in
the main as healthy as they had been during the previous nine
months. Adding these two periods together, we have three years
of immunity from the ordinary evils of surgical hospitals, under
circumstances which, but for the antiseptic system, were espe-
cially calculated to produce them.§
It may be well to mention in detail some facts regarding the
comparative frequency, before and after the period referred to,
of the three diseases to which surgical wards have hitherto
* I doubt if even my sense of the importance of the subject I am dealing with would
have induced me to enter into these disagreeable details, were I not able at the same time
to bear my testimony to the zealous manner in which the managers of the Infirmary and
the Town Council are exerting themselves to correct the evils referred to. I understand
that it is in contemplation to abolish entirely intra-mural interment in Glasgow.
t About half the wards of the fever hospital are used for surgical cases.
X The rapid increase of Glasgow has rendered the Infirmary, in spite of considerable
additions of late years, quite inadequate to the wants of the population; but this evil vail
shortly be remedied by the construction of a general hospital in connexion with the new
College.
§ The antiseptic system was commenced nearly five years ago, but was for the first
two years employed almost exclusively in compound fractures and abscesses, which form
but a small proportion of surgical cases, so that the system cannot be said to have been in
operation for more than three years with reference to the subject of the present paper.
Antisepsis and Surgical Hospital 89
been peculiarly liable— namely, pyaemia, erysipelas, and hospital
gangrene.
And first of pyaemia. This fearful disease used to occur princi-
pally in two classes of cases — namely, compound fractures and
the major amputations. In compound fracture, it was so rife
just before . the introduction of the antiseptic system that I had
one of the sulphites administered internally as a prophylactic, in
accordance with Polli’s views, to every patient admitted with
this kind of injury; though I cannot say that we observed any
distinct evidence of advantage from the practice. But since I
began to treat compound fractures on the antiseptic system,
while no internal treatment has been used, I have not had
pysemia in a single instance, although I have had in all thirty-two
cases — six in the forearm, five in the arm, eighteen in the leg, and
three in the thigh. These cases do not include those in which the
injury was so great as to demand immediate amputation. But
it must be remarked that many of the limbs saved were so severly
injured that I should formerly have removed them without
hesitation. I almost forget the kind of considerations which used
to determine me to amputate under the old treatment; though I
know that experience taught us that it was only in comparatively
mild cases that it was justifiable to attempt to save the limb.
Now, however, there is scarcely any amount or kind of injury
of bones, joints, or soft parts which I regard as inconsistent with
conservative treatment, except such destruction of tissue as
makes gangrene of the limb inevitable as an immediate
consequence.
But I may take this opportunity of observing that the attempt
to save a limb which, under ordinary treatment, would be sub-
jected to immediate amputation, ought not to be made lightly, or
without a thorough acquaintance with some trustworthy method
of carrying out the antiseptic system; by which I mean, not the
mere use of an antiseptic, however potent, but such majjagement
of the case as shall effectually -prevent the occurrence of putrefaction
in the part concerned. Without this such endeavors are far worse
than useless; for by the time that local disturbance and consti-
tutional disorder have made it apparent that the antiseptic
Medical Classics
90
means have failed, the patient is so much prostrated by irritation
and blood-poisoning, that the operation, if performed, is probably
too late; and thus a loose and trifling style of “giving the treat-
ment a trial” swells the death-rate at once of compound fracture
and of amputation.
On the other hand, the surgeon will not on this account be justi-
fied in contentedly pursuing the old practice of primary amputa-
tion; for the antiseptic means which it has been the main labor
of the last five years of my life to improve are now so satisfactory*
that anyone duly impressed with the importance of the subject,
and devoting to it the study and practical attention which it
demands, will, with little trouble to himself, securely attain the
results which he desires.
I lately visited my wards in Glasgow after an absence of some
weeks, and saw, amongst other cases, a compound dislocation of
the ankle in a man who had fallen about four feet from the plat-
form at a railway station, and lighted on the outer side of the
right foot, which had been forced violently inwards, producing a
contused and lacerated wound, about four inches long, crossing
the external maleolus, and communicating with the articulation.
When I saw the patient the wound had been converted into a
superficial sore, cicatrising rapidly; and there had been from first
to last no deep-seated suppuration, nor any local or constitu-
tional disturbance. I asked my then house-surgeon, Mr. James
Coats, with whom the most critical part of the treatment had
rested, whether he could reckon pretty securely upon such results.
He replied, “With certainty.” I asked the question for the
sake of others who were standing by, having little doubt what
the answer would be, for when I left him in charge I felt sure that
the antiseptic management of the cases would be as satisfactorily
conducted as if I were present.
At the same time, it is only right to add, that when he entered
upon his office, though convinced of the truth of the theory of
the antiseptic treatment, he by no means felt the confidence in
* I hope to bring before the profession the improved antiseptic means above alluded to
bp publishing from time to time in The Lancet cases illustrative of their employment.
Antisepsis and Surgical Hospital 91
carrying it out which he has since acquired; and if an able man
like Mr. Coats, inbued with the principles which I have striven
to establish, required some practical initiation into the subject
before he could be regarded as trustworthy, still more must such
be the case with those who, educated in the old system, and long
habituated to its practice, have to unlearn cherished ideas and
instinctive habits.
But, returning from this digression, I must now speak of
pyasmia after the major amputations, before and after the intro-
duction of the antiseptic system.
The hospital records are unfortunately imperfect for one of the
three years immediately preceding the antiseptic period. In the
other two years, the mortality after amputations in my wards
may be gathered from the following tables; —
Before the Antiseptic Period
1864
Seat of Amputation No. of Amputation* Recoveries Dcatiis
Shoulder 1 o 1
Arm 3 1 2
Forearm 3 2 1
Thigh 1 1 o
Leg 4 3 1
Knee 2 1 1
Ankle 3 ^ 1
Totals 17 10 7
1866
Arm 2 1 1
Elbow 1 o 1
Forearm 2 1 0
Thigh 4 0 4
Knee 6 4 2
Leg 1 1 0
Ankle 2 1
Totals *8 9 9
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92
On the other hand we have —
During the Antiseptic Period
1867
Scat of An petition No. of Amputation* Recoveries Death*
Arm 1 1 0
Forearm 2 2 o
Knee 220
Leg 1 1 o
Ankle 1 1 o
Totals ‘ 7 7 0
1868
Shoulder 1 1 o
Forearm 2 2 o
Thigh 1 1 o
Knee 853
Ankle 550
Totals 17 14 3
1869
Shoulder 220
Arm 2 2 o
Forearm 2 1 1
Thigh 1 o I
Knee 3 2 I
Leg 3 3 0
Ankle 3 3 °
Totals 16 13 3
Comparing the aggregate results, we have —
Before the antiseptic period, 16 deaths in 35 cases; or 1 death
in every 2 1-5 cases.
During the antiseptic period, 6 deaths in 40 cases; or I death in
every 6 2-3 cases.
These numbers are, no doubt, too small for a satisfactory
statistical comparison: but, when the details are considered, they
are highly valuable with reference to the question we are con-
sidering. This is especially the case with amputation in the
upper limb, where neither injuries requiring primary amputa-
tion nor the operations involve, as a general rule, much loss of
blood or shock to the system; so that, if death does occur, it is
Antisepsis and Surgical Hospital 93
commonly the result of the would assuming unhealthy char-
acters. It happens that there were 12 amputations altogether
in the upper limb in each of the two periods referred to. On the
12 cases before the antiseptic period, no fewer than 6 died— a
frightful mortality certainly. And it is recorded that, of those
6, 4 died of pyemia, and 1 of hospital gangrene. Also that one
of those which recovered had pyaemia; but, though the symptoms
were well marked and severe, presented an example, unhappily
too rare, of recovery from the disease.
Very different was the result of corresponding amputations
during the antiseptic period. Eleven of the 12 cases recovered;
and the one death which did occur was not the result of the opera-
tion, but took place in spite of it, from pyaemia, which had
resulted from fetid suppuration in a metacarpal bone, and con-
tinued after I had removed the hand, in the faint hope that the
constitutional mischief might be thrown off when its original
source had been taken away. Some of the successful cases, I
may add, were by no means favorable subjects for operation:
as, for instance, a completely shattered hand in a very aged
person; the avulsion by machinery of nearly the entire arm, one
of the flaps of the amputation at the shoulder-joint being left
contused and lacerated as it had been formed by the injury;* and,
again, an enormous osteoid cancer of the upper end of the
humerus, involving the deltoid muscle, and permitting only the
formation of skin flaps, attended with profuse haemorrhage, in a
patient already anaemic from the disease.
In the lower limb, 28 amputations in all were performed during
the antiseptic period. Out of these, death took place in 5; hut
was generally sufficiently accounted for by the severity of the
case, as when the thigh was amputated immediately below the
hip-joint in a patient greatly exhausted by haemorrhage from
malignant disease; or, to take another example, when primary
amputation was performed at the knee on one side, and imme-
diately below it on the other, in a man who had sustained %er)
severe injuries to both legs, and had been transported a con-
siderable distance by railway to Glasgow.
* This case vras treated by my colleague, Dr. Dunlop, during m> te-.-porary ab.e
Medical Classics
94
In one case only did pyaemia result from the operation — viz.,
after amputation at the knee in a young man of weakly constitu-
tion, where putrefaction occurred in the stump through mis-
management. Here the symptoms of pyaemia presented
themselves during life, and the femoral vein was found loaded
with pus on dissection. When putrefaction occurs after such an
operation, there is no security against pyaemia, even in private
practice; and. a single instance of the kind in three years, and
that in a feeble subject, is certainly no evidence of any peculiarity
in the hospital atmosphere.
In mentioning the fact that putrefaction occurred from mis-
management, I do not wish to be understood as implying that
it can always be avoided in stumps. In the present state of
surgical practice, this is far from being the case. When sinuses
exist in connexion with a diseased joint, putrefaction is present
in them at the outset; and even if they are injected with an anti-
septic solution before the operation, it can never be certain that
the liquid penetrates to every recess of these often complicated
passages, or destroys the vitality of the putrefactive organisms,
lurking, perhaps, in portions of lymph or slough. And if a single
such organism remain alive, it will propagate and spread in the
wound as soon as the antiseptic applied at the time of the opera-
tion has been absorbed into the circulation; and any external
antiseptic dressing will, under such circumstances, be of course
entirely nugatory. It is, I suspect, for want of bearing this point
in mind that disappointment has often been experienced in apply-
ing antiseptic treatment to amputations and excisions. The full
possible benefits of the system can never be obtained in such cases
till it shall be deeply impressed upon the profession and the public
that abscesses, more especially those in connexion with diseased
joints, must never either be allowed to break of themselves, or
be opened without antiseptic precautions.*
* The practice which I have found to answer best in amputations and excisions in parts
affected with sinuses is, after injecting the sinuses with a powerful antiseptic, to apply to
the cut surface a pretty strong solution of chloride of zinc (say forty grains to an ounce
of water), such as was recommended by Mr. Campbell De Morgan, and then employ an
external antiseptic dressing, in the hope, though never in the certainty, that putrefaction
Antisepsis and Surgical Hospital 95
I am bound to add that there is another respect in which the
antiseptic principle has not yet had justice done to it in the
larger amputations in the lower limb. Of all incised wounds,
these have proved the most difficult to manage; and putrefaction
has repeatedly occurred in my practice, even where no sinuses
were present. It was so in the two cases above referred to, of
amputation just below the hip-joint for malignant disease, and
double primary amputation for injury. Considering the condi-
tion of those patients on the day after the operation, I believe
both would have recovered had we succeeded in avoiding putre-
faction, which, apart altogether from the risk of pysemia, terribly
aggravates formidable cases, like those, by the irritation and
prostration which it occasions. Hence we may fairly look for
better results in the future from amputation in the lower limb.
For I am satisfied that the difficulties of the antiseptic manage-
ment are not insuperable. I have devoted much attention to
this branch of the subject during the last twelve months, and
steady progress has been made in it; so that the proportion of
stumps in which healing has taken place without any deep-seated
suppuration has been markedly increasing, and I anticipate that
before long we shall be able to reckon with certainty on the
absence of putrefaction in all cases where sinuses are not present.
But to return to the subject of pyasmia. The two cases above
alluded to were the only instances of its occurrence in my depart-
ment during the antiseptic period. One of them requires further
notice here. It belonged to a class of injuries in which the
benefits of the antiseptic system have been conspicuously ap-
parent — namely, severe contused wounds of the hand or foot,
such as are very frequent in a great centre of manufacture like
Glasgow. Formerly there were no injuries more unsatisfactory
to deal with. The uncertainty of the extent of the damage
inflicted by the contusion made it a most perplexing question
will be avoided. Chloride of zinc, having the peculiarity of producing a remarkably
persistent antiseptic effect upon the cut surface, protects it during the dangerous period
preceding granulation, when the recently divided tissues are both sensitive and prone to
absorption; so that even if putrefaction dow occur, the risk of inflammation and pyaemia
is greatly diminished.
Medical Classics
96
where amputation should be performed. On the one hand., if too
little was removed, sloughing of the flaps ensued, or diffuse
suppurative inflammation of the weakened tissues infiltrated with
extravasated blood; and, on the other hand, if it was determined
to avoid that error and to amputate through perfectly sound
tissues, an extravagantly large portion of the limb was often
sacrificed. It is therefore an unspeakable satisfaction to be able
to avoid amputation althogether in such cases, merely taking
away such portions as may be actually destroyed, and leaving the
weakened tissues in the vicinity to recover themselves quietly,
instead of perishing under the irritating and poisoning influence
of putrefaction; while any dead portions that may remain are
absorbed more or less completely, like the extravasated blood,
and replaced by tissue of new formation. If the history of all
the contused wounds of the hands and feet that have been treated
in my wards during the last three years were recorded, including
many compound fractures not reckoned as such in our classifica-
tion and several compound dislocations, it would be enough to
convince the most sceptical of the advantages of the antiseptic
system.
But the case to which I am now alluding was an exception to
the general rule of satisfactory progress. It was a severe injury
to the hand from machinery. My then house-surgeon, who had
only just entered upon his office, and had not as yet the confi-
dence in the antiseptic system which he soon afterwards acquired,
took it for granted that I should amputate the hand, and com-
mitted the error of leaving it till my visit on the following day,
without adopting efficient antiseptic measures. When I saw the
case I decided to try to save the greater part of the hand, and
endeavored to correct the mistake which had been made. Putre-
faction, however, ensued, and after some days pyaemia occurred,
and continued, as before stated, in spite of amputation of the
hand. On dissecting the parts, one of the metacarpal bones
was found split up, with putrefactive suppuration developed in
its interior. Under such circumstances pyaemia might occur in
a perfectly sound constitution and in the most healthy atmos-
phere, just as, in Cruveilhier’s highly instructive experiment.
Antisepsis and Surgical Hospital 97
suppurative phlebitis of the femoral vein and its branches,
exactly corresponding to that which is seen in traumatic pysemia,
was induced in a healthy dog by introducing into the vessel a'
bit of wood which, from its porous nature, could not but originate
putrefaction.*
Considering, then, the circumstances of the only two cases of
pyaemia which have occurred in my department during the three
years of the antiseptic period, I am justified in saying that the
wards have been completely freed from their former liability to
this frightful scourge.
Next of erysipelas, a disease which, though not so fatal as
pyaemia, used not unfrequently to occasion death amongst my
patients. During the antiseptic period several cases have been
admitted into my wards from without, but one only has originated
in them. This occurred in a young man with disease of the foot,
accompanied by sinuses extending into the leg. I performed
amputation at the ankle, but putrefaction continued in the
sinuses; and after the lapse of a considerable period erysipelas
occurred in connexion with them. He recovered from the
complaint, and after a while went to his lodgings for change of
air, with the sinuses still unhealed, and subsequently had another
attack of erysipelas there implying that the tendency to it was
in his own system rather than in the locality. That such was
really the case was afterwards fully demonstrated. The sinuses
refusing to heal, and disease recurring in the bones, he was re-
admitted under my care, and I performed amputation in the leg
above the sinuses. The stump healed without any deep-seated
suppuration, presenting a very good example of the result of a
modification of Mr. Teale’s method of amputation; and I re-
quested him to ascertain, by Mr. Teale’s plan of introducing
circular pieces of flannel into the socket of the artificial limb,
how much of his weight he could conveniently rest upon the end
of the stump. As he did not call to report the result on the day
arranged, I inquired into the cause, and learned that the stump
* See Cruveilhier’s Anatomic Pathologique, livraison where will also be found die
records of important experiments, proving how readily liquids introduced into the interior
of bones pass into the general circulation.
Medical Classics
98
had been seized with a third attack of erysipelas, although
perfectly cicatrised without sinus or sore of any kind.* Thus,
as regards erysipelas, our only exception to perfect immunity
from the disease during the three years was one that strikingly
proves the rule.
It remains to speak of hospital gangrene. This was formerly
both frequent and severe amongst my patients. It often griev-
ously marred the most promising results of surgery, and some-
times committed fearful ravages. Thus, I have known a boy
admitted with a small superficial wound near the elbow, in which
hospital gangrene occurring caused such destruction of tissue,
deeply as well as superficially, in spite of the most energetic
treatment, that it became necessary to amputate the limb.
Now and then it led to a fatal result, as in one of the amputations
before referred to. In that case I removed the arm at the
shoulder-joint for injury in a boy, and for some time all went on
well, till I regarded him as perfectly safe; but hospital gangrene
came on in the stump, and, advancing insidiously in all directions,
defied my best attempts to check it, and had reached beyond the
sternum before the poor fellow sank exhausted from its effects.
The contrast under the antiseptic system has been most
striking. For the first nine months, as. before mentioned, we had
not a single case of the disease. Since that time it has shown
itself now and then, but in a mild form, invariably yielding to
treatment, never occurring in recent cases, but only in old sores
weakened by the influence of surrounding cicatrix. But even
this has been very rare, and I do not recollect more than one
example of it during the last year. In short, hospital gangrene,
like pysmia and erysipelas, may be said to have been banished
by the antiseptic system.
Such being the case, I have insensibly relaxed in different ways
my former vigilance regarding the wards. I have allowed cribs
for children to be introduced without remonstrance, having
practically the effect of increasing the number of beds for adults;
and I have, in the pressure of deficient accommodation, often
* This case seems to me to possess considerable interest, as something intermediate — *
as it were a connecting link — between traumatic and idiopathic erysipelas.
Antisepsis and Surgical Hospital 99
permitted two children to be put in one bed— a thing which I
should formerly not have thought of. I used to make a point of
having both the large fires in each ward kept alight night and
.day during the heat of summer, for the sake of making the
ventilation as perfect as possible. But during the last season the
nurses were left to follow their inclination, and keep only one of
the fires lighted. I may add that my wards have remained
during the three years without the annual cleaning, which used
to be thought essential. On my asking the superintendent the
reason for the omission, he replied that, as those wards had con-
tinued healthy, and there was nothing dirty in their appearance,
it had seemed unnecessary to disturb them. Thus the wards
have been in various respects subjected to greater trial than
usual, and yet have remained, as I may repeat without any
exaggeration, models of healthiness.
That such should have been the case under the unfavorable
hygienic conditions above referred to seems at first sight very
surprising. The immediate vicinity of a burying-ground such as
has been described, together with the position of the wards at
the base of an hospital of four stories, with the air confined by
neighboring buildings, may seem conditions utterly inconsistent
with health in the patients. That these circumstances were very
unfavorable is undoubtedly true; and that they were highly
injurious before the antiseptic period seems clearly indicated by
our experience. But a little consideration will show that it is
not unreasonable to suppose them of secondary importance — as
aggravators of the evil, rather than the essential causes of it.
The corpses in the places of sepulture beside the infirmary were
for the most part covered by at least some inches of earth, which
has a most powerful effect in checking the evolution of noxious
effluvia; and even the foul gases from the open pits were perpet-
ually diluted by the air with which they mingled, so that but a
small proportion of them would enter the wards; and accordingly,
when the patients were cleared out for the purpose of the annual
cleaning, there was nothing in the wards to offend the nose. But
the emanations from sores are poured directly into the confined
atmosphere in which the patients are: and anyone familiar with
IOO
Medical Classics
the faint sickly smell commonly perceptible in surgical wards
under ordinary treatment, and still more with the stench which
prevails at the time of the daily dressing, will readily understand
that putrid exhalations from the patients may be a source of
mischief, compared with which the other circumstances alluded
to may be of comparatively trifling consequence.
With the object of getting rid of this great evil as much as
possible, I have used antiseptic means, not only where they are
of essential importance for the treatment of the individual case
concerned, as in recent wounds and abscesses, but also in super-
ficial sores. For though granulating surfaces will commonly heal
well enough under a putrid dressing (for such the cleanly water
dressing becomes within a few hours of its application), every
case so treated furnishes its quota to the vitiation of the general
atmosphere of the ward. Hence, for the sake of the inmates
generally, it is obviously desirable that healing sores should be
dressed with some application which, while permitting, or, if
possible, favoring, cicatrisation, should prevent odor. For this
purpose some dressing, unstimulating, but at the same time
persistent in antiseptic action, is requisite, — a combination which
I have sought in various different forms to obtain, and, of late
more especially, with very satisfactory results, so that while the
healing of superficial sores proceeded with greater rapidity than
under water dressing, all my sixty patients might sometimes be
dressed without the odor of putrefaction being perceptible in one
of them.
The result of this great change has been such as to demonstrate
conclusively that the exhalations from foul discharges are the
essential source of the insalubrity of surgical wards; and that
when this is effectually suppressed, other conditions, which we
are accustomed to regard as most pernicious, become powerless
to produce serious evil.
It is obvious that the facts recorded in this paper are of extreme
importance with reference to the vexed question of hospital con-
struction. With the view of assimilating the atmospheric
condition of our large hospitals to that of a private dwelling, it
has been lately proposed to do away with them altogether in their
IOI
Antisepsis and Surgical Hospital
present form, and to substitute for them congeries of cast iron
cottages, capable of being occasionally taken down, cleansed,
and reconstructed, — a plan which, besides involving enormous
expense, would interfere most seriously with efficient supervision
of the patients, and with the teaching of students at the bedside.
But from what has been related above, it is plain that no material
alteration of the existing system will be required. We have seen
that a degree of salubrity equal to that of the best private houses
has been attained in peculiarly unhealthy wards of a very large
hospital, by simply enforcing strict attention to the antiseptic
principle. And, considering the circumstances of those wards,
it seems hardly too much to expect that the same beneficient
change which passed over them will take place in all surgical
hospitals, when the principle shall be similarly recognised and
acted on by the profession generally. The antiseptic system is
continually attracting more and more attention in various parts
of the world; and, whether in the form which it has now reached,
or in some other and more perfect shape, its universal adoption
can be only a question of time. The noble institutions of which
our country is justly pround, admirably adapted alike for the
treatment of the sick and the instruction of the student, will then
be cleared of the only blot that now attaches to them, the
malignant influence of impure atmosphere.
Edinburgh , December , iS6p.
MEDICAL CLASSICS
vol. z October, 1937 N0 . 2
CONTENTS
Portrait of Johann von Mikulicz-Radecki - - - 106
Johann von Mikulicz-Radecki
Biography - -- -- -- -- -- 107
Eponyms - -- -- -- -- -- 108
Bibliography of Writings - - - - - - no
Biographies - -- -- -- -- - 128
Index to Bibliography - -- -- --129
Ueber eine eigenartige symmetrische Erkrankung
der Thranen- und Mundspeicheldrusen.
Prof. Dr. Johann Mikulicz ------ 137
Concerning a Peculiar Symmetrical Disease of
the Lacrymal and Salivary Glands. Prof.
Dr. Johann Mikulicz - - - -165
Chirurgische Erfahrungen iiber das Darmcarcinom.
J. von Mikulicz - -- -- -- -- 188
Surgical Experiences with Intestinal Carcinoma.
J. von Mikulicz
210
MEDICAL CLASSICS
vol. ii October, 1937
NO. 2
Johann Von Mikulicz-Radecki
Austrian Surgeon, 1850-1905
BIOGRAPHY
1850 Born May 16, in Cernowicz, in Bukowina, then a part of
Austria, now Rumania. Educated at Herrmannstadt.
Earned his way through the University by giving lessons
on the piano and playing on the organ from 5 to 8 A. M.
1875 Age 25. Degree of Doctor of Medicine at Vienna. Be-
came assistant to Billroth.
1879 Age 29. Visited Lister in England and Volkmann in
Germany.
1880 Age 30. Qualified as Privat-docent in surgery in Vienna.
1882 Age 32. Became director and Professor of Surgery at
Krakow, lectured in Polish.
1886 Age 36. First treated cancer of esophagus by resection
and plastic transplantation and introduced lateral
pharyngotomy in excising malignant tumors of tonsillar
region (Garrison).
1887 Age 37. Became director of the Clinic and Professor of
Surgery at Konigsburg.
1888 Age 38. First described condition we now call Mikulicz’s
disease, published in detail in 1892.
1890 Age 40. Became Professor of Surgery at Breslau, held
position until his death.
1902 Age 52. Described in detail the two stage resection of
tumors of intestine.
I 9°5 Age 55. Died on June 14, following an operation for
malignancy of the stomach.
107
io8
Medical Classics
Had 8 children, 4 sons and 4 daughters. Only surviving
son (1930) is Prof. Dr. Felix Von Mikulicz-Radecki of the Uni-
versity Frauenklinik of Berlin.
Mikulicz was an accomplished musician and was a friend of
Brahms.
EPONYMS
Cells: “Foam cells/’ the cells in rhinoscleroma which contain
the bacilli of the disease (Bacillus rhinoscleromatis). See
bibliographic reference No. 1, 1876.
Dictum: It is highly dangerous to give a general anesthetic to a
patient whose hemoglobin is below 30. See bibliographic
reference No. 65, 1890.
Disease: Chronic, hypertrophic enlargement of lacrymal and
salivary glands. See bibliographic reference No. 71, 1892
and complete, original article with English translation in
this monograph.
Drain: For large cavities where wicks are to be removed gradu-
ally; a square of gauze with silk cord in its center is placed
into cavity and packed with gauze wicks. See bibliographic
reference No. 14, 1881.
Kentrotribe: An instrument to crush an intestinal spur in
artificial anus, pressure being obtained by an elastic band
around the handles, giving a more gradual pressure than
with a screw. Illustrated in Handb. d. prakt. Chir., 1903}
1 Aufl., Vol. Ill, p. 193.
Line: Also called Mikulicz-Hartmann line, on stomach, used as
position for clamp in gastric resection. Line extends from
right of midline on greater curvature, nearly to cardia on
lesser curvature, allowing excision of pylorus, whole of lesser
curvature nearly up to esophagus, corresponding half of
greater curvature, right half of great omentum, whole of
lesser omentum, glands and lymphatics in the neighborhood
of the celiac axis artery, all in one piece. Illustrated in
ibid., Vol. IV, p. 173.
Mask: A frame covered with gauze and worn over the mouth
and nose of the operating surgeon.
Johann Von Mikulicz-Radecki 109
Ointment: For atonic granulation tissue, consisting of Balsum
of Peru 10 parts, silver nitrate 1 part, petrolatum 100 parts.
Operation: Foot, osteoplastic resection of; also called Wladi-
miroff-Mikulicz operation, consisting of excision of astragalus
and calcaneus with apposition of cut ends of cuboid and
scaphoid to cut ends of tibia and fibula, weight of body
then resting on distal ends of metatarsal bones. See
bibliographic reference No. 15, 1881.
Operation: Gastroenterostomy, also called Mikulicz-Czerny
operation; by using a transverse incision in jejunum three
or four inches from its origin and an incision close to the
greater curvature of the stomach, a suture anastomosis
allows the stomach to drain at the lowest point without
possibility of kinking the intestine. See bibliographic
reference No. 99, 1897 and Handb. d. prakt. Chir., 1903,
Vol. Ill, p. 175.
Operation: Hip, reduction of congenital dislocation, by means
of extension. See bibliographic reference No. 86, 1894.
Operation: Intestines, resection of, by two stage or exterioriza-
tion method; also called Mikulicz-Bruns method of colec-
tomy. See bibliographic reference No. 124, 190a and
complete, original article with English translation in this
monograph.
Operation: Nasal lobule, shortening of elongated, by partial
excision. See bibliographic reference No. 32, 1883.
Operation: Pharyngotomy, for exposure of tonsillar tumors.
See bibliographic reference No. 37, 1884.
Operation: Pyloroplasty, also called Heinecke-Mikulicz opera-
tion; a longitudinal incision at pylorus is sutured transversely
so that caliber is increased. See bibliographic reference
No. 57, 1887.
Operation: Rectum, prolapse of; transverse incision through
all layers of rectum into peritoneal cavity, excision of pro-
lapsed segment and reunion of ends. See bibliographic
reference No. 29, 1883.
Operation: Tarsectomy; see osteoplastic resection of foot.
Operation: Torticollis, excision of-^sternomastoid muscle. See
bibliographic reference No. 87, 1895.
1 1 o Medical Classics
BIBLIOGRAPHY OF WRITINGS
A — Army Medical Library.
B — New York State Library.
C — New York Academy of Medicine Library.
D — Kings County Medical Society, Brooklyn, Library.
E — Lane Medical Library of Stanford University.
I. Obcr das Rhinoslderom (Hebra). (On rhinoscleroma
(Hebra).) Arch. f. klin. Chir., 20: 485, 1876.
а. Bcitragzur Genese der Dermoide am Kopfe. (Contribution
to the origin of dermoids of the head.) Wien. med.
Wochcnsch., 1876.
3. Ijber individ Formdifferenzen am Femur und an der Tibia
des Menschen, mit Berucksichtigung der Statik des
Knicgclenks. (On the individual differences in form of
the human femur and tibia, with regard to the equilibrium
of the knee joint.) Archiv. Anat. Physiol. (Anatom,
abthg.), pp. 351-404, 1878. Also: Arch. f. klin. Chir.,
23, 1879.
4. t)bcr die Beziehungen des Glyzerius zur Coccobacteria
scptica und zur septischen Infektion. (Relation of
glycerine to the septic cocci and to septic infection.)
Ibid., 22, 1878. Also: 75 pp., 8°, Berlin, 1878, in A.
5. Die seitlichen Verkrummungen am Knie und deren Heilugs-
methoden. (Genu varum of the knee and its method of
cure.) Arch. f. klin. Chir., 23: 561-629; 671-770, 881-
SS4, 1879. Also rep.: Wien. med. Presse, 20: 117-119,
l8?9 :
б. Subperiostale Exstirpation der ganzen Scapula. Voll-
standige Regeneration. (Subperiosteal removal of the
entire scapula. Complete regeneration.) Arch. f. klin.
Chir., 24, 1879.
7. Die antiseptische Wundbehandlung und ihre Technik.
(Antiseptic wound treatment and its technique.) Mit-
tcil. d. Ver. d. Aerzte in Nieder-Oesterriech, 5: 58577;
92-95; 122-124; 146; 161; 183-187, 1879.
Ill
Johann Von Mikulicz-Radecki
8. Exstirpation solider Geschwulste des Uterus und der Liga-
menta Lata durch die Laparotomie. (Extirpation of
solid tumors of the uterus and of the lateral ligaments
by laparotomy.) Wien. med. Wochensch., 29: 513;
544; 57 6 ; 599“ 6o2 > i 8 79-
9. Uber eine Methode zur Aufrichtung eingesunkener Nasen.
(A method of restoring a sunken nose.) Ibid., 1201-1206.
Also: Anz. a. k. k. Gesellsch. d. Aerzte in Wien, pp. 19-21,
• l8?9 '
10. tlber Totalexstirpation des Uterus. (Panhysterectomy.)
Wien. med. Wochensch., 30: 1281; 1309; 1419; 1880;
3i:9; 37; 935 15°; i8 45 215; 241-245, 1881.
11. Zur Sprayfrage. (The question of sprays.) Arch. f. klin.
Chir., 25: 707-751; 1880. Also: 45 pp., 8°, Berlin, Schu-
macher, 1880, in A.
12. Osteomyelitis und Periostitis der rechten Scapula. (Osteo-
myelitis and periostitis of the right scapula.) Wien,
med. Presse, 1880, in A.
13. Bericht uber einen Fall von Kompression der Trachea durch
ein Aortenaneurysma. (Report of a case of compression
of the trachea by an aortic aneurism.) With Zemann.
Ibid., 1404. Also: Anz. d. Ges. d. Aerzte in Wien, 1881.
14. tlber die Anwendung der Antisepsis bei Laparotomien, mit
besonderer Riicksicht auf die Drainage der Peritoneal-
hohle. (Use of antisepsis in laparotomies, with special
regard to drainage of the peritoneal cavity.) Arch. f.
klin. Chir., 26: 111-150, 1881.
15. Eine neue osteoplastische Resektionsmethode am Fusse.
(A new method of osteoplastic resection of the foot.)
Ibid., 494-501. Also: Langen’s Arch., Bd. 26, Hft. 2.
Also: Chirurgenkongress, 1881. Also: 8 pp., 1 pi., 8°,
Berlin, Schumacher, 1881, in A & C.
16. Demonstration eines geheilten Falles von osteoplastischer
Resektion des Fusses nach seiner Methode. (Demonstra-
tion of a cured case of osteoplastic resection of the foot
by his (Mikulicz) method.) Prag. med. Wochensch., 6:
236, 1881.
I 12
Medical Classics
17. Demonstration desLeiterscher Warmeregulators. (Demon-
stration of Lei ter’s Heat-regulator.) Chirurgenkongress,
1881.
18. Zur Nervesdehung bei Erkrankungen des Ruckenmarks.
(On nerve stretching in diseases of the spine.) With N.
Weiss. Wien. med. Wochensch., 31: 1013; 1045; ^ 069;
1149; 1200; 1258; 1312; 1397; 1477532: 96; 1885357, 1881.
Also: Mitth. d. Wien. med. Doct.-Coll., 8: 177-122, 1882.
19. t)ber Gastroskopie und Oesophagoskopie. (On gastroscopy
and esophagoscopy.) Wien. med. Presse, 22: 1405-
1408; 1437; 14735 1505; 1537; 1573; 1629, 1881. Also:
Allg. Wien. med. Zeitg., 26: 456, 1881. Also: Wien, med
Bl., 4: 1362-1364, 1881. Also: Zentralbl. f. Chir., 8:
673-676, 1881. Also: Anz. d. k. k. Gesellsch. d. Aerzte
in Wien, pp. 15-18, 1881. Also: 32 pp., 8°, Wien., Urban,
1881, in A. Also: Chirurgenkongress, 1882. Also:
Mitth. d. Ver. d. Aerzte in Nied.-Oest., Wien, 8: 23-28,
1882.
20. Beitrage zur Kenntniss und chirurgischen Behandlung der
puerperalen Pyohemie mit Einschluss einiger progredien-
ter nicht metastatischer Entzundungsprocesse im Puer-
perium. (Contribution to the knowledge and surgical
treatment of puerperal pyemia including some extending
but not metastatic processes in the puerperium.) With A.
Felsenreich. Zeitsch. f. Heilk., 2: 112-153, 1881.
21. Demonstration an der Leiche der Pylorusresektion. (Dem-
onstration on the cadaver of pyloric resection.) Demon-
stration der von Billroth bisher resezierten Pylorusstucke.
(Demonstration of Billroth’s resection of a portion of the
pylorus.) Chirurgenkongress, 1881.
22. "Ober die Verwendung des Jodoforms bei der Wundbehandl-
ung und dessen Einfluss auf fungose und verwandte Pro-
zesse. (Application of iodoform in wound treatment and
its influence on fungoid and related processes.) Chirur-
genkongress, 1881. Also: Wien. med. Presse, 22: 734-
737, 1881. Also: Wien. med. Wochensch., 31: 649-65L
1881. Also: in Polish, O zyciu jodoformu w leczeniu
Johann Von Mikulicz-Radecki 113
tan. Przegl. lek., Karkow, ao: 481; 493; 505; 519;
534; 547> 564; 577; 593> 1881. Also: Arch. f. klin. Chir.,
27: 196-239, 1882.
23. Weitere Erfahrungen iiber die Verwendung des Jodoforms in
der Chirurgie. (Further experiences in the use of iodo-
form in surgery.) Berl. klin. Wochensch., 18: 721 ; 741,
1881. Also: Mitth. d. Wien. med. Doct.-Coll., 7: 413-
4I9, 1881. Also: 23 pp., 8°, Berlin, Schumacher, 1881,
in A. Also: Wien. Klinik, 8: 1-39, 1882. Also: English
translation in The Best Surgical Dressing, by O. K.
Newell, pp. 1 5-1 1 9, 1888. Also: Berliner klin.
Wochensch., 19: 62, 1882. Also: Centralbl. f. Chir.
9: I, 1882.
24. Die Bedeutung der modernen Chirurgie fur den kiinischen
Unterricht. (The significance of modern surgery on
clinical instruction.) Wien. med. Wochensch., 32; 1415-
1420, 1882. Also: in Polish, O wplywie chirurgii
nowoczesnejma ksztalcenie uczniow w klinice chirur-
gicznej. Przeglad lekarsk., Krakow, 21: 569-572, 1882.
25. Przyczynki do chirurgii. (Introductory lecture to surgery.)
Przegl. lek., Krakow, 22: 1; 17, 1883.
26. t)ber einen geheilten Fall von giinstig verlaufener Pylorus-
resektion, nebst Bemerkungen fiber ein gastroskopisches
Symptom des Magenkarzinoms. (A case of resection
of the pylorus with favorable progress to recovery to-
gether with remarks on a gastroscopic symptom of
gastric carcinomas.) Chirurgenkongress, 1883. Also:
Centralbl. f. Chir., 1883. Also: Wien. med. Wochensch.,
33 : 7°5; 745 > 1883. Also: Przegl. lek., Krakow, 22:
157; 169, 1883.
27. Zweikindskopfgrosses interstitielles und orangegrosses sub-
seroses Myofibrom des Uterus. Exstirpation durch die
Scheide; Heilung. (Interstitial myofibroma of the uterus
twice as large as a child’s head and a subserous one as
large as an orange. Extirpation through the vagina;
recovery.) Wien. med. Wochensch., 33: 269-273, 1883.
Also: Przegl. lek., Krakow, 22: 17; 29, 1883.
1 14 Medical Classics
28. Skoliosometer, ein Apparat zur Messung der Skoliose.
(Scoliosometer, an apparatus for measurement of scolio-
sis.) Chirurgenkongress, 1883. Also: Centralbl. f. Chir.,
10: 305-311, 1883. Also: Przegl. lek., Krakow, 22:
141-143, 1883.
29. Invagination und Prolaps des Dickdarms durch den Mast-
darm; Resektion eines 76 cm. langen Darmstuckes;
Heilung. (Intussusception and prolapse of large intes-
tine through the rectum; resection of 76 cm. of intestine;
recovery.) Wien. med. Press, 50: 1565; 51: 1597-1602,
1883. Also: Gazeta lekarska, Warszawa, 2. s., 3: 901-
903, 1883.
30. Zur Gussenbauerschen Operationsmethode bei fibrosen
Nasenrachenpolypen. (The operation of Gussenbauer
for fibrous naso-pharyngeal polypi.) Prag. med.
Wochensch., 8: 409; 417, 1883. Also: Przegl. lek.,
Krakow, 22: 53-55, 1883.
31. Zwei Falle von osteoplastischer Fussresektion nach eigener
Methode. (Two cases of osteoplastic resection of the
foot by his particular method.) Report in Wien. med.
Wochensch., 33: 1485-1490, 1883. Also: Przeglad lek.,
Krakow, 22: 441 ; 455, 1883.
32. Przycznki do plastycznej chirurgii nosa. (Contribution to
plastic surgery of the nose.) Gazeta lekarska, Warszawa,
2. s., 3: 429; 453, 1883. Also: Arch. f. klin. Chir., 3° :
106-118, 1884.
33. Erste Hilfe fur Verwundete. (First aid for wounded.)
Org. d. milit.-wissenschaftl. Ver., 27, 1883.
34. Przyczynek do techniki operacyjenej in nastopomego
leczenia raka migdalkow. (Operation in gangrene of
tonsils and after-treatment.) Przegl. lek., Krakow, 22:
597; 609, 1883.
35- tlber die Bedeutung der Bluttransfusion und Kochsalzinfu-
sion bei akuter Anamie. (The importance of blood trans-
fusion and common salt infusion in acute anemia.)
Wien. Klin., 10: 181-199, 1884.
36. O dzisiejszym stanie nauki o transfuzyi. (The present
Johann Von Mikulicz-Radecki 115
state of knowledge respecting transfusion.) Prezgl. lek.,
Krakow, 23: 177; 189; 201, 1884.
37. Zur Operation des Tonsillarkarzinoms; ein Beitrag zur
Pharyngotomie. (The operation for carcinoma of tonsil;
a contribution to pharyngotomy.) Deutsch. med.
Wochensch., 10: 33-35, 1884.
38. fiber Laparotomie bei Magen- und Darmperforation.
(Laparotomy for perforation of stomach and intestine.)
Naturf.-Versamml. Magdeburg, 1884. Also: Volkmann’s
Samml. klin. Vortr., No. 262, Chir., No. 83: 2307-2334,
1885. Also: Przegl. lek., Krakow, 24: 89; 105; 165;
179; 208, 1885.
39. Beitrage zur Wundbehandlung. (Contributions to wound
treatment.) Wien. med. Wochensch., 34: 1045; 1069;
i ° 995 IJ 53 ; h8ij 1212; 1273; x 357 ; l 39 e > i 88 4< Also:
Przegl. lek., Krakow, 23: i; 55; 70; 393; 411; 421; 433;
. 44 Si 553 ; 5 6 5 > i88 4 -
40. fiber den Wert des Jodoforms fur Wunden in Schleim-
hauthohlen. (Value of iodoform for wounds in cavities
of mucous membrane.) Wien. med. Presse, 25: 1154,
1884. Also: Inter, med. Kongr., Kopenhagen, 1884, 8:
114-121, 1 885.
41. Antiseptik bei der Laparotomie. (Antisepsis in laparot-
omy.) Ibid., 1884, pp., 40-44, 1886.
42. fiber einige Modifikationen des antiseptischen Verfahrens.
(Modifications of antiseptic treatments.) Chirurgen-
kongress, pp. 8-14, 1884. Also: Centralbl. f. Chir., 1884.
Also: Arch. f. klin. Chir., 31 : 435-488, i88 5 *
43. Zur Blutstillung durch Tamponade und Kompression. (The
arrest of hemorrhage by tamponade and compression.)
Chirurgenkongress, pp. 3 I- 33 ? i 88 4- Also: Centralbl.
f. Chir., 1884. Also: Arch. f. klin. Chir., 31: 489-493?
.. i88 5 -
44. tlber die Resektion des Kropfes, nebst Bemerkungen uber
die Folgezustande der Totalexstirpation der Schilddriise.
(Resection of goiter, with remarks on the results of total
removal of the thyroid.) Centralbl. f. Chir., 1885*
n6 Medical Classics
45. O resekcyi wola wraz zu wagami o nastepstwach calkowitego
wyluszczenia gruczola tarcykowego. (Paralysis of the
muscles of the larynx shortly after extirpation of goiter.)
Przegl. lek., Krakow, 24: 609, 1885.
46. O tradzie. liber den Aussatz. (Tragedy. Concerning
leprosy.) Ibid.
47. Przyczyneck do operacyi wola ze szczegolnem uwzglednier-
niem zlych nastepstw. (Extirpation of goiter with singu-
larly complicated sequelae.) Gazeta lek., Warszawa,
2. s., 6: 5; 26, 1886.
48. Beitrag zur Operation des Kropfes. (Contribution to the
operation for goiter.) Wien. med. Wochensch., 36:
1 ; 40; 70; 97, 1886.
49. Ein Fall von Resektion des karzinomatosen Oesophagus mit
plastischen Ersatz des erzidierten Stuckes. (Case of
resection of carcinomatous esophagus with plastic sub-
stitution of the elevated portion.) Prag. med.
Wochensch., II : 93, 1886. Also: 5 pp., 8°, Prag., 1886,
in A.
50. Zur Prioritatsfrage der osteoplastischen Resektion am
Fusse. (Question of priority in osteoplastic resection of
the foot.) Arch. f. Idin. Chir., 23, 1886. Also: Przegl.
lek., Krakow, 25: 109-m, 1886.
51. tlber die Ausschaltung toter Raume aus der Peritonealhohle,
mit besonderer Rucksicht auf die Exstirpation der aus
der Beckenhohle ausgehenden Geschwiilstc. (Closing off
of dead space from the peritoneal cavity with special
regard to the extirpation of tumors arising in the pelvic
cavity.) Chirurgenkongress, Pt. 2, pp. 187-209, 1886.
Also: Centralbl. f. Chir., 24, 1886. Also: Arch. f. klin.
Chir., 24: 635-657, 1887.
52. Die seitliche Pharyngotomie behufs Exstirpation maligner
Geschwulste der Tonsillargegend. (Lateral pharyn-
gotomy for extirpation of malignant swellings of the
tonsillar region.) Deutsch. med. Wochensch., 12: 157;
178, 1886. Also: Przegl. lek., Krakow, 25: 173, 1886;
26:351,1887.
Johann Von Mikulicz-Radecki 117
53. Przyczynki do chirurgii jamy brzusznej. (Contributions to
surgery of abdomen.) Przegl. lek., Krakow, 25: i; 17;
47; 63; 78; 127, 1886.
54. Zur operativen Behandlung des Empyems der Highmor-
shohle. (Operative treatment of empyema of the antrum
of Highmore.) Chirurgenkongress, 1886. Also: Cen-
tralbl. f. Chir., 13, 1886. Also: Pamietnika towarz lek.,
Warszawa, 82: 261-262, 1886. Also: 8°, Leipzig, 1886,
in A. Also: Arch. f. klin. Chir., 34: 626-634, 1887.
Also: Zeitschr. f. Heilk., Prag., J: 257-265, 1887. Also:
10 pp., 1 pi., 8°, Berlin, Hirschwald, 1887, A.
55. O fizyjologicznem zachowaniu sie przefykn i mechanizmie
pofykania u czfomieka. (Physiological behavior of the
pharynx and the mechanism of swallowing in man.)
With N. Czbulski. Krakow, Ak. (Mat.-Przyrod.) Rozpr.,
15: 203-210, 1887.
56. Opatrunek trwaly i leczenie ran pod wilgotnym strupam
krwi. (Permanent dressings and treatment of wounds
by scabbing.) Przegl. lek., Krakow, 26: 21; 2 9, 1887.
57* Zur operativen Behandlung der Pylorusstenose. (Opera-
tive treatment of pyloric stenosis.) Zur operativen
Behandlung des stenosierenden Magengeschwures. (Op-
erative treatment of stenosing ulcers of the stomach.)
Chirurgenkongress, 1887. Also: Centralbl. f. Chir., 14,
1887. Also: 8°, Leipzig, 1887, in A. Also: Arch. f. klin.
Chir., 37: 79-90, 1888. Also: 12 pp., 8°, Berlin, Hirsch-
wald, 18883 in A.
58. tlber extrabukkale temporare Resektionen des Unter-
kieferastes als Vorakt der seitlichen Pharyngotomie und
der Resektion des 3. Trigeminusastes. (Extrabuccal
temporary resection of the ramus of the lower jaw pre-
vious to lateral pharyngotomy and resection of 3rd
branch of fifth cranial nerve.) Abstract of Society
report in Berl. klin. Wochensch., 39: 736, 1887.
59. Erfahrungen fiber den Dauerverband und die Wundheilung
ohne Drainage. (Experiences in permanent dressing
n8 Medical Classics
and wound treatment without drainage.) Klin. Jahrb.,
I, 1888.
60. Zur operativen Behandlung des Prolapsus recti et coli in-
vaginati. (Operative treatment of prolapse of rectum
and intussusception of colon.) Chirurgenkongress, 1888.
Also: Verhandl. d. deutsch. Gesellsch. f. Chir., Berl.,
17: pt. 2 , 294-317, 1888. Also: Centralbl. f. Chir., 15,
1888. Also: 8°, Leipzig, 1888, in A. Also: Arch. f.
klin. Chir., 38: 74-97, 1889.
61. Weitere Erfahrungen iiber die operative Behandlung der
Perforationsperitonitis. (Further experiences in the op-
erative treatment of perforative peritonitis.) Chirurgen-
kongress, 1889. Also: Verhandl. d. deutsch. Gesellsch. f.
Chir., 18: pt. 2, 303-331, 1889. Also: Centralbl. f. Chir.,
1889. Also: Arch. f. klin. Chir., .39: 756-784, 1889.
Also: Wien. med. Bl., 39: 889, 1889.
62. Zur Behandlung der Pseudarthrose. (Treatment of pseudo-
arthrosis.) Chirurgenkongress, 1889. Also: Centralbl.
f. Chir., 1889.
63. Laparotomie wegen Wanderniere, Bestreichen des Peri-
tonealuberzuges derselben mit Jodoformkollodium, Repo-
sition der Niere, Heilung in 2 Fallen durch Verwachsung
mit dem benachbarten Peritoneum. (Laparotomy for
floating kidney, coating its peritoneal covering with
iodoform-collodium, replacing the kidney. Cure in 2
cases by adhesions with neighboring peritoneum.) Zeit-
schrift f. Geb., 19, 1890.
64. Infusion of salt solution and transfusion of blood in acute
anemia; their relative value. Translated by O. K.
Newell. 16 pp., 8°, Boston, Parkhill, 1890, in A & C.
65. tlber den Hamoglobingehalt des Blutes bei chirurgeschen
Erkrankungen, mit besonderer Rucksicht auf den Wieder-
ersatz bei Blutverlusten. (Hemoglobin content of the
blood in surgical diseases, with special regard to replace-
ment of blood loss.) Chirurgenkongress, 1890. Also:
Wien. med. Wochensch., 40: 803-804, 1890. Also:
Centralbl. f. Chir., 1890.
Johann Von Mikulicz-Radecki 119
66. Die bisherigen Erfolge des Kochschen Heilverfahrens gegen
Tuberkulose. (Results, up to the present time, of Koch’s
method of treatment of tuberculosis.) Deutsch. med.
Wochensch., 17, 1891. Also: 25 pp., 8°, Leipzig, Thieme,
1891, in A.
67. t)ber die in der Kgl. chirurgischen Klinik mit dem Kochschen
Heilmittel gewonnenen Erfahrungen. (Experiences in
the Kgl. surgical clinic with Koch’s treatment.) Jahresb.
d. Schles. Gesellsch. f. Vater. Kult., 1891, Bresl., 69:
med. abth., 18-22, 1892.
68. Uber die Behandlung brandiger Briiche. (Treatment of
gangrenous herniae.) Naturf.-Vers. Halle, 1891. Also:
Berl. klin. Wochensch., 29: 209; 249; 277; 305, 1892.
69. Zur Feier der 25 jahrigen Lehrthatigkeit Theodore Billroth’s
in Wien. (Commemoration of Theodore Billroth’s. 25
years as a teacher in Vienna.) Deutsche med.
Wochensch., 18: 913-915, 1892.
70. Die heutige Chirurgie und der chirurgische Unterricht.
(Present day surgery and surgical instruction.) Klin.
Jahrb., Berl., 4: 24-44, 1892.
71. Uber eine eigen artige symmetrische Erkrankung der
Thranen-und Mundspeicheldriisen. (A peculiar sym-
metrical disease of the lacrymal and salivary glands.)
Beitr. z. Chir. Festschr. f. Theodor Billroth, Stuttg., pp.
610-630, 1892. Also: 22 pp., 8°, Stuttgart, Enke, 1892,
in A.
72. Paul Michelson. Biography. Deutsch. med. Wochensch.,
18, 1892. Also: 2 pp., 8°, Leipzig, 1892, in A.
73. Demonstration eines Falles von Thoraxresektion wegen
Chondrosarkoms. (Demonstration of a case of resection
of the thorax for chondrosarcoma.) Naturf. Vers. Halle,
1892.
74. Atlas, der Krankheiten der Mund- und Rachenhohle.
(Atlas of diseases of mouth and pharyngeal cavity.)
With P. Michelson. 89 1 ., 44 pi., roy. 8°, Berlin, Hirsch-
wald, 1892, in A, B, C and E.
,75. Bibliotheca medica. Hrsg. Kocher, Konig & Mikulicz, 1893.
120
Medical Classics
76. Nachtragliche Bemerkungen zur Witzelschen Methode der
Gastrostomie. (Additional observations on Witzel’s
method of gastrostomy.) Berl. klin. Wochensch., 30:
}> 1893.
77. Die Entwickelung der Chirurgie an den deutschen Univer-
sitaten. Werk zur Chicagoer Weltausstellung: “Die
deutschen Universitaten.” (The development of surgery
in German universities. A work for the Chicago Exposi-
tion: “The German Universities.”) Berlin, Asher, 1893.
78. Article on operation for bleeding gastric ulcer (gastric
hemorrhage). Congress of French Surgeons, 1893.
7 9. Stereoskopischer medizinischer Atlas. (Stereoscopic medi-
cal atlas.) With A. Neisser & Partsch. Leipzig, Barth,
1894.
80. Der heutige Stand der Magenchirurgie. (Present state of
stomach surgery.) Allgem. med. Centralzeit., 1894.
81. Theodor Billroth. Berl. klin. Wochensch., 1894.
82. t)ber den Ersatz von grosseren Hautdefekten durch Trans-
plantation ungestielter Hautlappen nach der Methode
von Krause. (Substitution of large skin defects by
transplantation of a sessile skin flap by the method of
Krause.) Dermatologenkongress, 1894.
83. Zur chirurgischen Behandlung der Hautmaler. (Surgical
treatment of moles.) Ibid. Also: 3 pp., 8°, Wien,
1894, in C.
84. Zur Behandlung der Tuberkulose mit Stauungshyperamie
nach Bier. (Treatment of tuberculosis with passive
hyperemia according to Bier.) Centralbl. f. Chir., 21:
26 5“ 2 73> 1894.
85. Chloroform oder Aether? (Chloroform or ether?) Berl.
klin. Wochensch., 31: 1035-1039, 1894. Also: 13 pp., 8°,
Berlin, 1894, in C.
86. Die unblutige Reduktion der angeborenen Hiiftverrenkung.
(Bloodless reduction of congenital dislocation of the hip.)
Arch. f. klin. Chir., 49: 368-386, 1894. Die blutige und
unblutige Reduction der congenitalen Huftluxation.
(Open and closed reduction of congenital dislocation of
I 2 I
Johann Von Mikulicz-Radecki
the hip.) Attid. XI Cong. med. internaz. 1894, Roma, 4:
chirurg., 411, 1895.
87. Uber die Exstirpation des Kopfnickers beim muskularen
Schiefhals, nebst Bemerkungen zur Pathologie dieses
Leidens. (Extirpation of sterno-mastoid for muscular
torticollis, with remarks on the pathology of this affec-
tion.) Centralbl. f. Chir., 22: 1-9, 1895.
88. t)ber Thymusfutterung bei Kropf und Basedow’scher
Krankheit. (Feeding of thymus in goiter and Basedow’s
disease.) Berl. klin. Wochensch., 32: 342-346, 1895.
Also: 12 pp., 8°, Berlin, 1895, i n A.
89. Die chirurgische Behandlung der Basedow’schen Krankheit.
(Surgical treatment of Basedow’s disease.) Chirurgen-
kongress, 1895. Also: Verhandl. d. deutsch. Gesellsch.
f. Chir., 24: 21-29, Also: Ber. u. d. Verhandl. d.
Gesellsch. f. Chir., 24: 67-72, 1895.
90. Surgery of the stomach. Med. Week, Par., 3: 195, 1895.
91. t)ber ausgedehnte Resectionen der langen Rohrenknochen
wegen maligner Geschwiilste. (Extensive resection of
the long bones for malignant tumors.) Verhandl. d.
deutsch. Gesellsch. f. Chir., 24: pt. 2, 350-365, 1895;
discussion, pt. 1, 104. Also: Arch. f. klin. Chir., 50:
660-675, 1895. Also: Ber. u. d. Verhandl. d. deutsch.
Gesellsch. f. Chir., 24: 130, 1895. Also: Chirurgen-
kongress, 1895. Also: 17 pp., 1 pi., 8°, Berlin, 1895, in A.
92. Bericht fiber 103 Operationen am Magen. (Report on 103
Operations on the stomach.) Chirurgenkongress, 1895.
Also: Verhandl. d. deutsch. Gesellsch. f. Chir., 24: pt. 2,
737-767, 1895. Also: Arch. f. klin. Chir., 51: 9-39, 1895.
Also, abstr. : Ber. u. d. Verhandl. d. deutsch. Gesellsch. f.
Chir., 24: 72-76, 1895. Also: Toledo Med. & Surg.
Reporter, 9: 5 2 7 > Also: 31 pp., 8°, Berlin, 1896,
in A.
93. Weitere Erfahrungen fiber die unblutige Reduktion der
angeborenen Hfiftverrenkung. (Further experiences with
bloodless reduction of congenital dislocation of the hip.)
Chirurgenkongress, 1896. Also: Centralbl. f. Chir., 1896.
122
Medical Classics
94. Ein neues chirurgisches Taschenbestack, insbesondere fur
den Feldgebrauch bestimmt. (A new surgical pocket
dressing-case, especially designed for military use.)
Deutsch. militararztl. Zeitschr., 25: 156-161, 1896.
95. Local diseases of the mouth. With W. Kummel. In
Twentieth Century Practice of Medicine. N. Y., Wood,
9: 1-94, 1897.
(Same) Die Krankheiten des Mundes. With contribu-
tions by Czerny and Schaeffer. With W. Kummel.
ix, 253 pp., 2 pi., 8°, Jena, Fischer, 1898, in A, B, C and D.
(Same) 2. ed., vii, 295 pp., 8°, Jena, Fischer, 1909, in
A & C.
(Same) 3. ed., vii, 320 pp., 8°, Jena, Fischer, 1912, in
A & C.
(Same) 4. ed., vii, 338 pp., 8°, Jena, Fischer, 1922, in
C&D.
96. Das Operieren in sterilisierten Zwirnhandschuhen und mit
Mundbinde; ein Beitrag zur Sicherung des aseptischen
Yerlaufs von Operationswunden. (Operating in sterilized
linen gloves and with a mouth covering; a contribution to
securing an aseptic course in operative incisions.) Cen-
tralbl. f. Chir., 24: 713-717, 1897. Also: 4 pp., 8°,
Leipzig, 1897, in A.
97. t)ber Versuche, die aseptische Wundbehandlung zu einer
wirklich keimfreien Methode zu vervollkommenen. (Re-
search on improving aseptic treatment of wounds by a
practical germ-free method.) Deutsch. med. Wochensch.,
23: 409-413, 1897. Also: 13 pp., 8°, Leipzig, Thieme,
1897, in A.
98. Neubildungen des Rachens und des Nasenrachenraumes.
(New growths of the pharynx and naso-pharynx.) In
• P. Heymann’s Handbuch der Laryngologie und Rhino-
logie, Wien, 2: 385-445, 1897.
99. Die chirurgische BehandJung des chronischen Magengesch-
wiirs. (Surgical treatment of chronic gastric ulcers.)
Chirurgenkongress, 1897. Also: Centralbl. f. Chir., 24:
69-98, 1897. Also: Mitteil. a. d. Grenzgeb. d. Med. u.
Johann Von Mikulicz-Radecki 123
Chin, 2: 184-272, 1897. Also: Arch. f. klin. Chir., 55,
1897. Also: Berl. klin. Wochensch., 34: 488; 522; 561;
640, 1897. Also, abstr.: Deutsch. med. Wochensch.,
22: Ver.-Beil, 83, 1897. Also, abstr.: Jahresb. d. schles.
Gesellsch, f. vaterl. Cult., 1896, Bresl., 74; 1. Abt., Med.
.. Sect., 1 1 5-1 22, 1897. Also: 37 pp., 8°, Berlin, 1897, in A.
100. uber die neuesten Bestrebungen, die aseptische Wund-
behandlung zu vervollkommen. (The latest attempts
to improve aseptic wound treatment.) Chirurgenkon-
gress, 1898. Also: Centralbl. f. Chir., 1898. Also:
Arch. f. klin. Chir., 57: 243-279, 1898. Also: Verhandl. d.
deutsch. Gesellsch. f. Chir., 27: pt. 2, 1-37, 1898. Also:
37 pp., 8°, Berlin, 1898, in A.
101. Beitrage zur Technik der Operation des Magenkarzinoms.
(Contributions to the technique of operation for carcinoma
of the stomach.) Chirurgenkongress, 1898. Also: Arch,
f. klin. Chir., 57: 524-532, 1898. Also: Verhandl. d.
deutsch. Gesellsch. f. Chir., 27: pt. 2, 252-260, 1898.
Also, abstr.: Centralbl. f. Chir., 25: 118-121, 1898. Also:
10 pp., 8°, Berlin, 1898, in A.
102. Die heutige Chirurgie und der chirurgische Unterricht.
(Modern surgery and surgical instruction.) Klin. Jahr-
buch, 4: 24, 1898.
103. Discussionsbemerkungen zu dem Vortrage des Herren Dr.
Tietze (uber) die chirurgische Behandlung der acuten
Peritonitis. (Discussion of report of Dr. Tietze on
surgical treatment of acute peritonitis.) Allg. med.
Centr.-Zeitg., Berl., 67, 1898. Also: r 1 ., 8°, Berlin,
1898, in A.
104. Discussionsbemerkungen zu dem Vortrage des Herren Prof.
Kolaczek zur Frage der totalen Magenresection. (Dis-
cussion of report of Prof. Kolaczek on question of total
resection of stomach.) Allg. med. Centr.-Zeitg., Berl.,
67, 1898. Also: 1 1 ., 8°, Berlin, 1898, in A.
105. t)ber den heutige Stand der Chirurgie der Gallenwege.
(Modern attitude toward surgery of the bile-ducts.)
Allg. med. Centr.-Zeitg., 68, 1899. Also: 3 pp., 8°,
Berlin, 1899, in A.
124 Medical Classics
106. Zur Operation der angeborenen Blasenspalte. (Operation
for congenital ectopia of the bladder.) Centralbl. f.
Chir.j 26, 1899. Also: 1 1 ., 8°, Leipzig, 1899, * n A.
107. Die Desinfektion der Haut und Hande mittels Seifenspiritus.
(Disinfection of skin and hands by means of solution of
soap in spirits.) Deutsch. med. Wochensch., 25, 1899.
Also: 9 pp., 8°, Leipzig, Thieme, 1899, in A.
108. Handbuch der praktischen Chirurgie. By Bergman, Bruns
& Mikulicz. (Handbook of practical surgery.) 4 vols.,
8°, Stuttgart, 1899-1900.
(Same) Trattato di chirurgia pratica. Milano. Soc. edit,
libr., 1901.
(Same) 2. ed., in German, 1903.
(Same) In English, trans. by Bull et al., 5 vols., N. Y.
Lea, 1904.
(Same) 4. ed., in German, Stuttgart, 1913-14.
(Same) 5. ed., in German, Stuttgart, 1921-24.
(Same) 6. ed., in German, 6 vols. in 7, Stuttgart, F.
Enke, 1926-1931.
109. Discussionsbemerkungen des Herren Dr. Gottstein iiber
seltene Erkrankungen der Speiserohre und deren diag-
nostische Feststellung durch das Oesophagoskop. (Dis-
cussion of Dr. Gottstein on rare diseases of the esophagus
and their diagnostic determination by the esophagoscope.)
Allg. med. Centr.-Zeitg., Berk, 69, 1900. Also: 1 h, 8°,
Berlin, 1900, in A.
no. Die Verletzungen und Erkrankungen des Magens. (In-
juries and diseases of the stomach.) With W. Kausch.
Handb. d. prakt. Chir., Stuttg., 3: 234-316; 392-475,
1900.
in. Technik der Operationen am Magen-Darm-Kanal. (Tech-
nique of operations on the stomach and intestines.)
With W. Kausch. Ibid., 168-234.
1 12. fiber Ileus. (Ileus.) Therapie d. Gegenwart, n. s., 2:
438-450, 1900. Also: Allg. med. Centr.-Zeitg., 69, 1900.
Also: 6 pp., 8°, Berlin, 1900. Also: 13 pp., roy. 8°,
Berl. & Wien, 1900, in A.
Johann Von Mikulicz-Radecki 125
1 13. fiber die Narkose. Die deutsche Kiinik am Eingange des
20. Jahrhunderts von v. Leyden und F. Klemperer.
(Narcosis. The German Clinic at the beginning of the
20th century — .) 8, 1901. Also: 36 pp,, roy. 8°, Berlin
& Wien, 1901, in A.
114. Die Methoden der Schmerzbetaubung und ihre gegenseitige
Abgrenzung. (Methods of pain control and their respec-
tive limitations.) Chirurgenkongress, 1901. Also: Arch,
f. klin. Chir., 64, 1901. Also: 34 pp., 8°, Berlin, 1901, in A.
1 15. Discussionsbemerkungen zu dem Vortrage des Herren
Poufick fiber die Beziehungen der Scrophulose zur
Tuberculose. (Remarks in discussion of the report of
Herr Poufick on relation of scrofula to tuberculosis.)
Allg. med. Centr.-Zeitg., Berk, 69, 1901. Also: 1 1 .,
8°, Berlin, 1901, in A.
1 16. Zur operativen Behandlungen der Basedow’schen Krank-
heit. (Operative treatment of Basedow’s disease.) Allg.
med. Centr.-Zeitg., 69, 1901. Also: 3 pp., 8°, Berlin,
1901, in A.
1 17. fiber Thyreoidismus bei einfachem Kropf. (Thyreoidismus
in simple goitre.) With G. Reinbach. Mitteil. a. d.
Grenzgeb. d. Med. u. Chir., 8: 247-265, 1901. Also,
abstr.: Centralbl. f. Chir., 1: 52-54, 1902. Also: pp.
247-265, 8°, Jena, Fischer, 1901, in A.
1 1 8. Chirurgische Erfahrungen fiber Magencarcinom. (Surgical
experiences with carcinoma of stomach.) Centralbl. f.
Chir., 28: 1 1 97- 1 200, 1901. Also, abstr.: Versam. Deut.
Naturf. u. Arzte, sek. f. Chir.
1 19. Orthopadische Gymnastik gegen Rfickgratsverkrfimmungen
und schlechte Korperhaltung. (Orthopedic gymnastics
for curvature of spine and bad posture.) With Toma-
sczemski. xlii, 103 pp., 8°, Jena, Fischer, 1902, in A
and D.
(Same) 2. ed., 1904, in A. (Same) 3. ed., 1908, in A.
(Same) 4. ed., 1917*
120. Ein Fall von Ureterstein. (A case of ureteral stone.)
Schles. Gesellsch. f. vaterland. Kultur in Breslau, Nov.
28, 1902.
126 Medical Classics
121. Contribution to the treatment of fractured patella. Brit.
Med. Jour., 2: 1828-1831, 1902.
122. Ausgedehnte Darmresektion bei Ileocoloninvagination.
(Extensive resection of intestine for ileo-colic intussuscep-
tion.) Allg. med. Centr.-Zeitg., 1902.
123. Demonstration eines mit Erfolg operierten Falles von Oeso-
phagusdivertikel. (Demonstration of a case of diverticu-
lum of the esophagus with operative result.) Ibid.
124. Chirurgische Erfahrungen uber das Darmcarcinom. (Surgi-
cal experiences with intestinal carcinoma.) Chirurgen-
kongress, 1902. Also: Arch. f. klin. Chir., 69: 28-47,
1903. Also: La clinica moderna, Zaragoza, 1903. Also,
abstr.: Centralbl. f. Chir., i: 104-107, 1902.
125. Ein operativ geheilter Fall von Kardiospasmus. (A case of
cardiospasm cured by operation.) Allg. med. Centr.-
Zeitg., 1903.
126. Allgemeines uber Laparotomie. (Generalities on laparot-
omy.) With W. Kausch. Handb. d. prakt. Chir.,
(Bergmann), 2 Auf., Stuttg, 1903, in C.
127. Verletzungen und Erkrankungen des Magens und Darms.
(Injuries and diseases of the stomach and intestines.)
With W. Kausch. Handb. d. prakt. Chir., (Bergmann),
2 Auf., Stuttg., 3: 143-389, 1903. Also: 247 pp., 8°,
Stuttgart, 1903, in C.
128. fiber einen mit Rontgenstrahlen erfolgreich behandelten
Fall von Brustdrusenkrebs. (A case of cancer of the
mammary gland with results of treatment with x-ray
radiation.) Beitr. z. klin. Chir., 37: 676-697, 1903.
129. Small contributions to the surgery of the intestinal tract.
Trans. Amer. Surg. Assn., Phila., 21: 124-134, 1903.
Also: Bost. Med. & Surg. Jour., 148: 608-611, 1903.
130. tjber die Skoliose. (Scoliosis.) Kinder-Arzt., Leipzig, 14:
121-129, I 9°3* Also: Aerztl. Rundschau., Miinchen, 13:
34°~343> I 9°3*
131. Max Schade; Alfred Kast. Mitteil. a. d. Grenzgeb. d.
Med. u. Chir., 11, 1903.
Johann Von Mikulicz-Radecki 127
132. t)ber den heutigen Stand der Chirurgie des Pankreas, mit
besonderer Riicksicht auf die Verletzungen und Entzund-
ungen des Organes. (The modern attitude toward
surgery of the pancreas, with special regard to injuries
and inflammations of the organ.) Ibid., 12 : 1-24. Also:
Trans. Congr. Amer. Phys. & Surg., 6:55-79; 98-104, 1903.
133. Surgery of the pancreas. Ann. Surg., 38: 1-29, 1903.
134. Beitrage zur Physiologie der Speiserohre und der Kardia.
(Contributions to the physiology of esophagus and car-
dia.) Mitteil. a. d. Grenzgeb. d. Med. u. Chir., 12:
569-601, 1903.
135. Cystische Degeneration derlangen Rohrenknochen. (Cystic
degeneration of long bones.) N. Y. Med. W., 16: 83-90,
1904.
136. Zur Pathologie und Therapie des Kardiospasmus. (Pathol-
ogy and therapy of cardiospasm.) Deutsch. med.
Wochensch. 30: 17-19; 50-54, 1904.
137. Einiges fiber Naht und Nahtmaterial. (Briefly on suturing
and suture material.) Ibid., 415; 1463.
138. fiber Operationen in der Brusthohle mit Hilfe der Sauer-
bruchschen Kammer. (Operations in thoracic cavity
with aid of Sauerbruch’s air-chamber.) Ibid., 530; 577.
Also: Chirurgenkongress, 1904.
139. Die heutige Magen- und Darmchirurgie und ihre Bedeutung
fur den inneren Arzt. (Modern surgery on stomach and
intestines and its significance for the internist.) Deutsch.
Klinik am Eingenge des 20. Jahrhunderts, 8: 929-952,
1904.
140. Zur Pathologie der Gelenkkontrakturen. (Pathology of
joint contractures.) Zeitsch. f. orthopad. Chir., 13:
233- 2 4 r > I 9°4-
141. Multiple Knochentumoren. (Multiple bone tumors.)
Naturf.-Vers. Breslau, 1904.
142. Yersuche fiber Resistenzvermehrung des Peritoneums gegen
Infektion bei Magen- und Darmoperationen. (Experi-
ments on increasing the resistance of the peritoneum to
128
Medical Classics .
infection in stomach and intestinal operations.) Chirur-
genkongress, 1904. Also: Arch. f. klin. Chir., 73: 347-
368, 1904.
143. The Cavendish Lecture on experiments on the immunization
against infection of operation wounds, especially of the
peritoneum. Lancet, 1904. Also: West London Med.
Jour., 9: 157-180, 1904.
144. tiber perineale Prostatektomie. (Perineal prostatectomy.)
Naturf.-Yers. Breslau, 1904. Also: Munchen. med.
Wochensch., 51: 1765, 1904.
145. Sackartige Dilatation des Oesophagus. (Cystic dilatation
of esophagus.) Allg. med. Centr.-Zeitg., 1904.
146. Chirurgische Universitatsklinik Breslau. Deutsche Un-
terrichtsausstellung, Medizin. Weltausstellung, St.
Louis, 1904. (University Surgical Clinic at Breslau.
Demonstration of German Teaching in Medicine. World’s
Fair, St. Louis, 1904.
147 . Die Bedeutung der Rontgenstrahlen fur die Chirurgie.
(The importance of x-ray radiation to surgery.) Deutsch.
med. Wochensch., 31: 657-663, 1905.
BIOGRAPHIES
Biography by Sauerbruch. Munchen. med. Wochensch., 52:
1297-1300,1905.
Biography by Eiselsberg. Wien. klin. Wochensch., 18: 671-674,
1905. Also: Centralbl. f. Chir., 32: No. 26, 1905.
Obituary by A. Wolfer. Prag. med. Wochensch., 30: 366-368,
. I9 ° 5 -
Obituary by M. Blumberg. Deutsch. med. Presse, 9: 90, 1905.
Obituary. Boston Med. & Surg. Jour., 153: 64, 1905.
Obituary by J. F. Lehman. Munchen. med. Wochensch., No.
2/, 1905.
Biography by W. Ausschutz. Berl. klin. Wochensch., 42: 1163-
1165, 1905.
Biography. Brit. Med. Jour., 2: 49, 1905.
Biography by D. G. Zesas. Centralbl. f. d. Grenzgeb. d. Med. u.
Chir., Jena, 8: 449-453, 1905.
Johann Von Mikulicz-Radecki 129
Biography by Czerny. Deutsch. med. Wochensch., 31: 1039,
1 905-
Biography by J. S. Ibid., 999.
Biography. Jour. Amer. Med. Assn., 45: 58, 1905.
Biography. Lancet, 2: 122, 1905.
Biography by Pels-Leusden. Med. Klin., Berl., i: 734, 1905.
Biography by Naunyn. Mitteil. a. d. Grenzgeb. d. Med. u.
Chir., 14: i-vi, 1905.
Biography by Poufick. Jahresb. d. Schles. Gesellsch. f. vaterl.
Cult., 1905, Breslau, pp. 115-118, 1906.
Biography by W. Krausch. Johann von Mikulicz-Radecki.
Sein Leben und seine Bedeutung. Gedenkband fur J. von
Mikulicz — Mitteil. a. d. Grenzgeb. d. Med. u. Chir., 3
suppl., Jena, Fischer, pp. 1-58, 1907. Bibliography, pp.
58-64.
Festrede bei der Enthiillung des Mikulicz-Denkmals in Breslau
am 27 Mai 1909. Berl. klin. Wochensch., 46: 1495, I 9°9-
Mikulicz’s drain. Amer. Jour. Surg., 8: 1103, 1930.
Twenty-fifth anniversary of death of Mikulicz. By H. Kuttner.
Beitr. z. klin. Chir., 150: 1-6, 1930.
INDEX TO BIBLIOGRAPHY
Reference Year
Abdomen, surgery of 53 1886
Anemia, acute 35 1884
64 1890
Aneurism, aortic 13 1880
Antisepsis in laparotomies 14 1881
Antiseptic wound treatment 7 1879
22, 23 1881
42 1884
96, 97 1897
100 1898
Antrum of Highmore 54 J 886
Arthrosis, pseudo 62 1889
Atlas, medical 79 *^94
Basedow’s disease, see goitre.
130
Medical Classics
Bier’s treatment
Bile-duct surgery
Billroth, obituary
Billroth, resection of pylorus
Billroth, the teacher
Bladder, ectopia of
Blood in surgical diseases. . .
Blood transfusions
Bones, cyst of
Bones, malignancy
Bones, tumors
Breast, cancer of
Cardiospasm
Chloroform
Chondrosarcoma of thorax. .
Dermoids of head
Disinfection of hands
Dressing case
Dressings, permanent
Esophagoscope.
Esophagus, carcinoma. . .
Esophagus, dilatation . . .
Esophagus, diverticulum
Esophagus, physiology . .
Esophagus, resection
Ether
First-aid
Foot, resection of
Reference
Year
84
1894
i° 5
1899
81
1894
21
1881
69
1892
106
1899
65
1890
35
1884
1 35
i 9 ° 4
9 1
1895
141
J 9°4
128
1903
125
1903
136
1904
85
1894
73
1892
2
1876
107
1899
94
1896
56
1887
59
1888
19
1881
109
1900
49
1886
H 5
1904
123
1902
J 3 4
1903
49
1886
85
1894
33
1883
15, 16
1881
3 1
1883
5 °
1886
J 9
1881
76
1893
96
1897
Gastroscope
Gastrostomy, Witzel’s
Gloves, sterilized
Johann Von Mikulicz-Radecki 13 1
Goitre
Gussenbauer operation
Handbook of surgery
Heat-regulator, Leiter’s
Hemorrhage, arrest of
Hernia, gangrenous
Hip, congenital dislocation
Ileus
Immunization
Infections
Intestines, carcinoma
Intestines, injuries and diseases
Intestines, perforation
Intestines, surgery
Intussusception
Iodoform in wound treatment .
Joint contractures
Kidney, floating
Knee joint
Koch’s treatment
Krause skin graft
Lacrymal glands, disease of . . .
Laparotomies
Larynx, paralysis .
Reference
Year
44,45
1885
47 , 48
1886
88, 89
^95
n 6, 1 17
I9OI
3 °
I883
108
I899
'
et seq.
1 7
1881
43
1884
68
1891
86
1894.
93
1896
112
.1900
143
1904
4
1878
ia 4
: I902
IT]
* 9°3
38
1884
I29
* 9°3
139
1904
29
1883
60
1888
122
1902
22, 23
1881.
40
1884
1 40
1904
63
1890
3
1878
5
1879
66,6 7-.
1891
82
1894
7 i
1892
14
1881
41
1886
126
1 9°3
45
1885
I 3 2
Medical Classics
Reference Year
Leiter’s heat-regulator 17 1881
Leprosy 46 1885
Mammary gland, cancer 128 1903
Medical instruction 146 1904
Michelson, Paul 72 1892
Moles, treatment of 83 1894
Mouth, diseases of 74 1892
95 i8 97
et seq.
Narcosis 113 1901
Nasal polypi 30 1883
Nose, plastic surgery 32 1883
Nose, sunken 9 1 879
Pain, control of 114 1901
Pancreas, surgery of 132, 133 . 1903.
Patella fracture 121 1902
Peritoneal cavity 51 .1886
Peritoneal cavity drainage 14 1881
Pharyngotomy 37 1884
52 1886
58 1887
Pharynx, diseases of 74 1892
Pharynx, physiology 55 1887
Pharynx, tumors 98 1897
Prostatectomy 144 1904
Puerperal pyemia 20 1881
Pylorus, resection 26 1883
Pylorus, resection, Billroth’s 21 1881
Pylorus, stenosis 57 1887
Rectum, prolapse 60 . 1888
Rhinoscleroma 1 1876
Salivary glands, disease of 71 1892
Sauerbruch’s air-chamber 138 1904
Scapula, osteomyelitis 12 1880
Scapula, removal of 6 1879
Schade, Max 131 1903
Johann Von Mikulicz-Radecki 133
Reference Year
Scoliosis 28 1883
1 19 1902
et seq.
130 1903
Scrofula 115 1901
Skin graft 82 1894
Spine, diseases of 18 1881
Sprays 11 1880
Stomach, injuries and diseases no 1900
127 1903
Stomach, perforation 38 1884
Stomach, surgery 80 1894
90, 92 1895
101, 104 1898
in 1900
139, 142 1904
Stomach, ulcers 78 1893
99 1897
Surgical development 77 1893
Surgical instruction 24 1882
70 1892
102 1898
Suture material 137 1904
Swallowing, mechanism 55 1887
Thoracic cavity, surgery 138 1904
Thorax, resection 73 1 892
Thyroid, see goitre.
Tonsils, carcinoma 37 1884
52 1886
Tonsils, gangrene 34 1883
Torticollis 87 1895
Trachea, compression 13 1880
Tuberculosis, Bier’s treatment 84 1894
Tuberculosis, Koch’s treatment 66,67 1891
Ureteral stone 120 1902
Uterus, removal of 1880
134
Medical Classics
Reference
Year
Uterus^ tumors of
8
I879
27
I883
Witzel’s gastrostomy
7 6
l8 93
Wound treatment
7
i8 79
22, 23
1881
39
1884
X-ray in surgery
147
T 9°5
MIKULICZ’S DISEASE
Mikulicz reported a single case of chronic hypertrophy of the
lacrymal and salivary glands at a meeting of the Society for
Scientific Medicine at Konigsberg in 1888. He carefully perused
the literature for corresponding cases and four years later, at the
dedication of a volume of medical articles to his former chief,
Theodor Billroth, published a detailed description of the patient
with illustrations and reviewed a few other cases having some
similar characteristics reported by other observers.
In the original case swelling of the lacrymal glands appeared
first, followed by swelling in the submaxillary and parotid regions;
only the swelling near the eyes gave any disturbance, and then
interfered with vision only because of size. After removal of
about two-thirds of the lacrymal tumors, the swelling reappeared
in about two (?) months. Again surgical removal was instituted,
this time including the submaxillary glands also. Two months
later the patient reported himself in good health but a few days
later was stricken with what was probably appendicitis and died
in nine days. During this last illness all the swellings practically
disappeared.
Microscopically the portion of gland removed revealed “a
massive, small-cell infiltration of the interstitial connective tis-
sue,” “the true parenchyma of the glands playing an entirely
passive role.”
In his review of several cases from the literature, Mikulicz
shows that most of them do not correspond to his case; some
are of acute swellings or inflammations of the lacrymal gland
alone, others concern leukemic or tuberculous involvement of
salivary and lacrymal glands or of lymph nodes of the face or neck.
Finally, in summing up his knowledge, Mikulicz theorizes as to
the interrelation between lacrymal and salivary gland disease
extending by way of buccal and nasal mucosa. He believed the
causative factor to be “an infectious or parasitic process in the
broadest sense of the word.”
Following the recognition of this disease, many case reports
appeared. Then in 1907, Napp, O. (Ztschr. f. Augenh., 17:
513) declared the condition to be simply a symptom complex
that might be produced by any one of several causes, such as
leukemia, pseudoleukemia, atypical lymphomatosis and tuber-
culosis, An important milestone in the study of the condition
w r as an article by Howard, C. P, (Internet. Clin,, I: 30, 1900)
who classified all the cases he could find in the literature into three
groups, (1) Mikulicz’s disease proper, (a) pseudoleukemia and
(3) leukemia.
In 1927 Schaffer and Jacobsen (Am. J. Dis. Child., 34: 327)
reviewed all cases of this syndrome seen at the Johns Hopkins
Hospital and divided them into two groups: (1) symptomatic
and (2) Mikulicz’s disease proper. They maintain that the
syndrome can occur in leukemia, lymphosarcoma and tuberculosis,
possibly in syphilis, but that Mikulicz’s disease proper should be
reserved for those cases where a thorough search fails to reveal
any underlying or associated disease factors. (Editorial, Jour.
Amer. Med. Assn., 2 9, 1429, 1927.)
Thus we stand today exactly where Mikulicz did in 1892 when
he called for help in solving the riddle of this condition. We
know only that the disease seems to be a low-grade infection of
the lacrymal and salivary glands, extending over a long period
with possible spontaneous termination and never causing death.
The translation here given was made by Dr. W. de Rouvillc.
t
Ueber eine eigenartige symme-
trische Erkrankung der Thranen-
und Mundspeicheldrusen
VON
PROF. DR. JOHANN MIKULICZ
Direktor der chirttrgischen Klinik in Breslau
Mit Tafel IX und 5 Holzschnitten
From Beitrdge zur Chirurgte, Festschrift gew'tdmet Theodor Billroth von
seinen danhbaren Schulem zu jeier des vollendeten funfzigsten Semesters
seines akademischen Wirkens in Wien. Stuttgart , Enhe, 1892
N DER Sitzung vom 23. Januar 1888 stellte ich
im Yerein fiir wissenschaftliche Heilkunde zu
Konigsberg 1 einen Fall vor der ein eigentiim-
licheSj mir bis dahin unbekanntes Krankeitsbild
darbot. Beide Thranendriisen und sammtliche
Mundspeicheldrusen waren in symmetrischer
Weise zu Geschwiilsten umgewandelt, die sich aus dem normalen
Lager dieser Organe stark hervordrangten und dadurch das
Gesicht des Kranken in auffallender Weise entstellten. Die
Geschwulste waren allmahlich entstanden; sie waren zur Zeit der
t Untersuchung von derber Konsistenz, schmerzlos, ohne Spur von
entzundlichen Erscheinungen. Im ubrigen waren an dem Trager
dieser Tumoren keine krankhaften Veranderungen nachzuweisen.
Die Deutung dieses Krankheitsfalles setzte mich in die grosste
Verlegenheitj denn er passte nirgends in den Rahmen der bisher
bekannten und benannten Krankheiten. Auch fand ich in der
1 Berliner klin. Wochenschrift 1888, 759.
138 Medical Classics
Litteratur nicht eine einzige der meinigen analoge Beobachtung
verzeichnet. Ich hatte die Hoffnung, dass mir der Zufall einen
zweiten, ahnb’chen Fall in die Hande spielen und dadurch die
Auffassung des Krankheitsbildes erleichtern werde. Indessen
scheint die betreffende Affektion sehr selten zu sein, so dass ich
diese Hoffnung wohl aufgeben muss. Ueberdies sind in der
Zwischenzeit von anderen (p. 61 1) Beobachtern mehrere Falle
mitgeteilt worden, die dem meinigen entweder vollig gleichen oder
doch so ahnlich sind, dass sie zur Beurteilung des vorliegenden
Krankheitsprozesses herangezogen werden durfen.
Aus diesem Grande habe ich mich entschlossen, meinen Fall
schon heute ausfuhrlich mitzuteilen.
KRANKENGESCHICHTE
Der 4 2 jahrige, verheiratete Eigenkathner (kleiner Bauer)
Christof Kalweit aus Marienwalde in Ostpreussen hat vor 20
Jahren eine Lungenentzundung durchgemacht; sonst will er stets
gesund gewesen sein. Vor 7 Monaten, im Juni 18S7, bemerkte
er, dass beide obere Augenlider zu schwellen begannen; er hatte
dabei weder Schmerzen noch sonstige Beschwerden, nur wurde
mit zunehmender Schwellung das Oeffnen der Lider erschwert.
Spater verengte sich die Lidspalte derart, dass er im Sehen be-
hindert wurde. Bald darauf entwickelte sich unter beiden Kiefer-
winkeln eine ebenfalls schmerzlose Geschwulst, die im weiteren
Verlaufe beim Essen und Sprechen hinderlich wurde. Ueber die
Zeit der Entwicklung der anderen Anschwellungen vermag Pa-
tient nichts anzugeben, jedenfalls zeigten sie sich erst spater.
Nur die Beeintrachtigung im Gebrauch der Augen beunruhigte
den Kranken und fuhrte ihn zu einem Arzte, der ihm eine innere
Medizin verschrieb. Als dies erfolglos blieb, suchte er in der
chirargischen Klinik in Konigsberg Hilfe.
Befund am 13. Januar 1888. Kraftig gebauter, gut genahrter
Mann von sonst gesundem Aussehen. In den inneren Organen
keine Abweichungen nachweisbar. Insbesondere zeigen Leber,
Milz und Nieren keine Veranderungen; Urin eiweissfrei. Pan-
kreas nicht zu palpieren. Prostata nicht vergrossert. Nirgends
nachweisbare Lymph drasenschwellungen. Im Blut keine auffal-
Erkrankung der Drtisen
1 39
lenden Veranderungen, insbesondere keine Leukocythose. Seh-
nen- und Hautreflexe normal. Temperatur und Puls normal.
In auffallender Weise erscheint das Gesicht durch symmetrische
Anschwellungen im Bereich der oberen Augenlider, der Parotis
x ‘ ' ****$$? ; :
A I
d der Subn
dung Fig. a
D ie oberen
lfte. so wei
Medical Classics
140
dreieckigen Raum reduziert erscheint, dessen Basis die zwei in-
neren Drittel des unteren Lidrandes bilden. Im riusseren Drittel
beruhren sich die beiden Lidrander vollstandig. Pat. vermag
selbst unter (p. 612) starker Anstrengung das obere Lid nicht
merklich hoher zu heben. Infolgedessen bleibt dauernd das
ojossere, obere aussere Segment der Iris und Pupille vom oberen
Lid verdeckt. Wohl infolgedessen hat sich ein Strabismus con-
vemens entwickelt, durch welchen die Pupillen in den relativ wei-
teren medialen Teil der Lidspalte eingestellt werden.
Die ausseren zwei Drittel der oberen Augenlider sind ausserdem
halbkugelig nach vorn und aussen gewolbt, so dass hier die mitt-
Fig. B
lere Lidfalte fast verstrichen erscheint. Bei der Palpation findet
man hier unter der Lidhaut einen kleinhockerigen, derben Tumor
von quer ovaler Gestalt, der sich bis an den Orbitalrand verfolgen
lasst. Der Tumor selbst ist wenig beweglich, die leicht oderma-
tose Lidhaut uber demselben dagegen leicht verschiebbar (p. 613).
\\ird das obere Augenlid mit dem Finger stark in die Hohe ge-
zogen, so erscheint die aussere Halfte der Lfebergangsfalte durch
den beschriebenen Tumor so weit hervorgedrangt, dass sie bis
nahe an den Cornealrand reicht. (Vergl. nebenstehende Abbil-
dung Fig. B.) Conjunctiva selbst leicht gerotet und etwas ver-
dickt. Die Bulbi etwas nach innen und vorn dislociert, im
Erkrankung der Driisen 141
iibrigen keine krankhaften Veranderungen an ihnen nachweisbar.
Sehvermogen ungestort.
Die Parotisgegend beiderseits von einer flach gewolbten, ein-
heitlichen Geschwulst eingenommen, welche ihrem Sitze nach
genau der Lage der Ohrspeicheldriise entspricht; sie dehnt sich
nach vorn bis in die Mitte der Wange aus, lasst sich in die Nische
zwischen Kieferast und Warzenfortsatz verfolgen und hebt das
Ohrlappchen deutlich ab. Konsistenz derb elastisch. Ihre Ober-
flache ist scheinbar glatt, die Haut dariiber wenig verschiebbar.
Fig. C
\
Unter jedem Kieferwinkel ragt eine circa hiihnereigrosse, von
normaler, verschiebbarer Haut bedeckte Geschwulst hervor. Sie
ist etwas verschiebbar, von derber Konsistenz; ihre Oberflache
lasst stellenweise flache Hocker erkennen. Die beiden Tumoren
stossen in der Mittellinie fast zusammen.
Oeffnet Pat. den Mund, so fallen zunachst zwei den Sublin-
gualdriisen entsprechende Tumoren auf. Sie prasentieren sich
als zwei langliche Geschwiilste, welche, in Form und Grosse einer
auf die Kante s^estellten Mandel, den Boden der Mundhohle zu
Medical Classics
142
beiden Seiten des Frenulum linguae einnehmen. (Siehe Fig. A
a-a.) Sie reichen bis in die Hohe der Zahnkronen und lagern
sich so zwischen die Spitze der ruhenden Zunge und die Zahnreihe.
Die Schleimhaut iiber den Tumoren leicht geschwollen,
(p. 614) Fine kolossale Yergrosserung weisen die Gaumen-
driisen auf. (Siehe Fig. C.)
Der Gaumen ist beiderseits bis iiber die Grenze des weichen
Gaumens hinaus von je einer fast kastaniengrossen, scharfbe-
grenzten Geschwulst eingenommen. Beide Geschwulste reichen
bis an den Alveolarrand, lassen aber in der Mittellinie eine l cm
breite, nach vorn allmahlich breiter werdende Furche von nor-
malem Aussehen frei. Nach vorn reichen sie bis an den I. Prri-
molaris. Die Oberflache der Anschwellungen erscheint glatt, die
Schleimhaut dariiber unverandert, die Konsistenz prall elastisch.
Un ter der Wangenschleimhaut finden sich beiderseits vor dem
Ausfiihrungsgange der Ductus Stenonianus etwa erbsengrosse,
bewegliche Knoten (accessorische Driisen). Ausserdem liegen
noch weiter vorn, gegen das Vestibulum oris zu, mehrere bis erb-
sengrosse, bewegliche Knotchen unter der Wangenschleimhaut.
Wahrend der Untersuchung findet reichlich Speichelabsonde-
rung statt, doch sind sonst keine Erscheinungen von Speichelfluss
vorhanden. An der Mundschleimhaut keine auffallige Verati-
derung. Mehrere Zahne fehlen, einzelne sind carios.
Da nur die Anschwellung der Thranendriisen dem Kranken
hinderlich war, wurde zunachst eine partielle Entfernung der-
selben, soweit sie das Oeffnen der Lidspalte erschwerten, vorge-
nommen (p. 615) (1. Februar 1888). Circa i-J cm langer, hori-
zontaler Schnitt in der Yerlangerung der Lidspalte, Spaltung der
Konjunktiva iiber dem am meisten vorspringenden Teil des Tu-
mors. Die Druse wurde nun stumpf bis unter den Orbitalrand
freiprapariert und der entblosste Teil mit der Schere abs;etragen.
Naht der Hautwunde. Es wurde auf jeder Seite eine etwa 2l
cm lange, i-i§ cm im Durchmesser haltende Masse der Gesch-
wulst, nach meiner Schatzung ungefahr f des ganzen Tumors
entfernt. Es folgte glatte Heilung. Schon nach wenigen Tagen
Erkrankung der Driisen 143
war der funktioneUe Erfolg ein so evidenter, dass Pat. befriedigt
die Klinik verlassen konnte.
Die Besserung des Zustandes hielt jedoch nicht Iange an. Bald
kamen die Geschwiilste an den Augenlidern wieder zum Vorschein
und verengerten die Lidspalten fast in demselben Masse als vor
der Operation. Auch vergrosserten sich die Tumoren an den
Kieferwinkeln zusehends. Aus diesem Grande kam Pat. Ende
Marz abermals in die Klinik. Sammtliche Tumoren schienen um
Geringes an Umfang zugenommen zu haben. Die Anschwellung
der Thranendriisen hat fast den alten Umfang wieder erreicht. —
Es wird ein Versuch mit Pilokarpininjektionen gemacht, in der
Hoffnung, durch vermehrte Sekretion eine Volumsabnahme der
vergrosserten Driisen zu erzielen. Trotz reichlicher Salivation
ist ein Erfolg nicht zu konstatieren ; deshalb wird nach 18 Tagen
die Kur abgebrochen und auf dringendes Verlangen des Kranken
abermals zum Messer gegriffen. Am 19. April wird unter gleicher
Schnittfuhrung wie das erste Mai die ganze Thranendruse rech-
terseits exstirpiert. Die letzten tief gelegenen Reste werden mit
dem scharfen Loffel hervorgeholt. Glatte Heilung. Am 1. Mai
wird in gleicher Weise die Thranendruse entfernt. Gleichzeitig
werden auch beiderseits die vergrosserten Submaxillardrusen ex-
stirpiert. Sie liegen ebenso locker, wie die normale Druse, in
ihrem Lager, und lassen sich miihelos und unter geringfiigiger
Blutung ausschalen. Glatte Heilung per primam intentionem.
Nach 10 Tagen wird Pat. entlassen.
Ueber das weitere Schicksal des Kranken liegen nur briefliche
Berichte vor. Am 12. Juli, also 2 Monate nach seiner Entlassung,
schrieb er mir selbst, er sei mit seinem Zustande sehr zufrieden.
Die Anschwellung der Ohrspeicheldriisen scheine allerdings noch
zuzunehmen, sie behindere ihn aber nicht. Er sei im Gebrauche
der Augen gar nicht behindert, obwohl er den ganzen Tag in der
Sonnenhitze auf dem Felde arbeiten musse. Die Anschwellungen
am Halse (Submaxillardrusen) seien nicht w'ieder gekommen. Er
fuhle sich auch sonst ganz gesund.
(p.-6i6) Am 25. Juli erkrankte er plotzlich unter den Erschein-
ungen einer Peritonitis (Perityphlitis?), nachdem er noch Tags
vorher seiner Arbeit nachgegangen war. Er erlag der Krankheit
144 Medical Classics
am g. Tage. Die Geschwiilste in der Parotisgegend und im
Munde sollen sich wahrend dieser Erkrankung binnen wenigen
Tagen rapid zuriickgebildet haben, so dass sie vor dem Tode fast
verschwunden waren.
Ueber die anatomische Untersuchung der exstirpierten Teile
kann ich folgendes berichten. Am meisten Beachtung verdient .
die Untersuchung der Submaxillardriisen, welche in toto entfernt
worden sind. Zunachst muss hervorgehoben werden, dass jede
der auf Kinderfaustgrosse angeschwollenen Drusen in Bezug auf
Form und Gliederung in Lappen und Lappchen genau den Ver-
haltnissen der normalen Druse entsprach. Die Totalansicht und
der Querschnitt des Tumors, auf Taf. IX Fig. I und i dargestellt,
geben ein treues Bild davon. Der Tumor zeigte in den groberen
makroskopischen Einzelheiten den normalen Bau der Druse, nur
in’s Masslose vergrossert. Ein wesentlicher Unterschied fand
sich jedoch auf dem frischen Querschnitt schon fur das blosse
Auge in der Farbe und im feineren Gefuge der die einzelnen Lapp-
chen bildenden Driisenmasse. An Stelle des feinkornigen, grau-
rotlichen Gefuges der normalen Driisensubstanz sehen wir eine
mehr homogene, blassrotlichgelbe, speckige Masse von leichter
Transparenz. Die Konsistenz ist vermindert, speckig. Die Zahl
der Blutgefasse scheint nur in den Septis, der Grossenzunahme
des Organs entsprechend, vermehrt zu sein; die Driisensubstanz
selbst erscheint auffallend gefassarm.
Die mikroskopische Untersuchung ergab, dass die Hauptmasse
des Tumors aus einem ziemlich gleichmassig angeordneten Ge-
webe kleiner Rundzellen bestand. (Siehe Tafel IX, Fig. 3.) Die
Zellen liegen stellenweise dichter beisammen; an anderen Stellen
ist zwischen ihnen ein feines Retikulum zu erkennen. Verein-
zelte, grossere Zellen lassen deutlich Kernteilungsfiguren erken-
nen. In diese kleinzellige Hauptmasse eingebettet erscheinen,
teils einzeln, teils gruppenweise, die anscheinend unveranderten
Acini der Speicheldruse. Sie sind durch das Rundzellengewebe
gewissermassen auseinander gedrangt, auseinander geworfen.
Aehnliche Aerhaltnisse boten sich bei der mikroskopischen
Erkrankung der Driisen 145
Untersuchung der Thranendruse dar; nur dass hier die Acini weit
seltener anzutreffen waren und, wie es scheint, in den am meisten
nach aussen gedrangten Partieen der Geschwulst ganz fehlten.
(p. 617) Versuchen wir den beschriebenen Fall zu deuten, so
stossen wir auf mannigfache Schwierigkeiten. Der Krankheits-
prozess stellt sich klinisch als eine langsam entstehende, kolossale
Vergrosserung samtlicher Speichel- und Thranendriisen dar, ohne
entziindliche Erscheinungen, ohne nachweisbare Mitbeteiligung
des Gesamtorganismus. Der Prozess bleibt auf das Gebiet dieser
Driisen scharf beschrankt, er zieht weder die Nachbarschaft, noch
andere Organe und Gewebe in Mitleidenschaft. Die mikro-
skopische Untersuchung ergiebt, dass das eigentliche Driisen-
parenchym dabei eine ganz passive Rolle spielt. Die Grossen-
zunahme ist lediglich durch eine massenhafte, kleinzellige Infiltra-
tion des interstitiellen Bindegewebes bedingt.
Es ist klar, dass der mikroskopische Befund allein hier den
Prozess nicht erklaren kann. Ware eine einzige Druse in der ge-
schilderten Weise verandert, so wiirden wir nicht anstehen, an
eine echte Geschwulst zu denken. Wissen wir doch, dass gerade
in den Speicheldriisen, vom interstitiellen Bindegewebe ausge-
hend, die mannigfachsten Geschwiilste aus der Bindegewebsreihe,
zumal auch Rundzellensarkome, vorkommen. Einem typischen
Rundzellensarkom entspricht aber hier schon der histologische
Befund nicht; ausserdem widerspricht das makroskopische und
noch mehr das klinische Verhalten dem Bilde des echten Sarkoms.
Ich meine die strenge Respektierung der Grenzen der Druse und
ganz besonders der grosseren und kleineren Septa zwischen den
Driisenlappchen. Die histologische Beschaffenheit der klein-
zelligen Infiltration entspricht am ehesten dem Verhalten lympha-
denolden Gewebes. Demnach konnte man histologisch an ein
Lymphom oder Lymphosarkom denken. 1 Hiermit begeben wir
uns aber auf einen unsicheren Boden, auf ein Gebiet, in welchem
1 Ich habe nach der ersten mikroskopischen Untersuchung den Prozess in der That
als Lymphosarkom aufgefasst und in diesem Sinne auch Herm Prof. Fuchs in \N icn von
dem Falle Mitteilung gemacht.
Medical Classics
146
klinische Beobachtung und histologische Forschung noch nicht
vollig in Einklang gebracht sind und auf welchem die Nomen-
clatur noch recht unklar und zweideutig ist. Wir konnten zu-
nachst an jene Formen von Geschwfilsten denken, welche primar
von Lymphdrfisen oder von praformiertem lymphadenoiden Ge-
webe ausgehen und als maligne Lymphome (Pseudoleukaemie)
bezeichnet werden. Heidenhain 1 hat im interstitiellen Bindege-
webe der Speicheldrfisen, namentlich in der Sublingualis lympha-
tisches Gewebe nachgewiesen; gegen die Annahme einer primaren
Lymphombildung in der Speicheldrfise (p. 618) ist daher a priori
nichts einzuwenden. Das vollstandige Fehlen einer Mitbeteili-
gung der Lymphdrusen und der Milz — wie sie z. B. auch die sog.
Pseudoleukamie der Haut begleitet — spricht jedoch gegen den
Charakter maligner Lymphome.
Aber auch die Annahme eines LymphosarkomSj wir es ausser
den Lymphdrusen gelegentlich im Hoden und in anderen Organen
vorkommt, ist nach meiner Meinung nicht zulassig. So weit mir
die Falle dieser Art bekannt sind, handelt es sich immer um ma-
ligne Neubildungen, die frfiher oder spater Metastasen machen.
Der klinische Verlauf entspricht dem des typischen Sarkoms. In
unserem Falle war der klinische Verlauf wahrend der 14 monat-
lichen Beobachtung trotz des Recidivs von Seiten der Thranen-
drusen kein maligner; in den letzten Lebenstagen des Kranken
bildeten sich die nicht operierten Tumoren rapid zuriick. Ueber-
legen wir ferner, dass das fast gleichzeitige Auftreten zahlreicher
Erkrankungsherde an ortlich vollig getrennten Stellen unseren
Erfahrungen fiber bosartige Geschwfilste direkt widerspricht, so
mfissen wir die Annahme einer solchen in unserem Falle entschie-
den zurfickweisen.
Das Resultat unserer Betrachtung ist somit ein rein negatives.
Ueber die Bedeutung des Prozesses kann ich nur Vermutungen
aussprechen. Bevor ich aber die Gedanken ausspreche, die ich
mir in der Richtung gemacht habe, mochte ich die Falle anderer
Beobachter anfuhren, soweit sie zu dem meinigen in Beziehung zu
bringen sind.
1 Studien des physiologischen Institutes zu Breslau 1868, 4. Heft, S. 116.
Erkrankung der Drtisen 147
Die meiste Aehnlichkeit mit meinem Falle hat ein vor kurzem
von Fuchs 1 2 mitgeteilter, in welchem beiderseits die Thranendriisen
und Parotiden erkrankt waren. Ferner ein vor 3 Jahren mitge-
teilter Fall von HaltenhofP mit gleichzeitiger Anschwellung der
Thranendriisen, der Parotiden und Submaxillardriisen beider
Seiten.
Der Fall von Fuchs ist folgender:
6ijahriger, kraftiger Mann, von Beruf Glaser. Er bemerkte vor 5
Monaten eine Anschwellung der oberen Augenlider, vor 4 Wochen die
Geschwulst in der Parotisgegend. Vorstellung in der Klinik des Prof.
Fuchs in Wien im Marz 1890. Die beiden oberen Augenlider in ihrer
ausseren Halfte durch eine Geschwulst vorgetrieben, die im ausseren
oberen Teil der Orbita lag. Der vordere Rand der Geschwulst fuhlte
sich hart und hockerig an; die Lider selbst waren dariiber verschieblich.
Wurde das Lid stark in die Hohe gezogen, so erschien die Uebergangs-
falte (p. 619) in ihrer ausseren Halfte durch eine braunrote Geschwulst
vorgewolbt. Die Bulbi etwas vorgetrieben, im ubrigen intakt. Seh-
vermogen ungestort. — Anschwellung beider Ohrspeicheldrusen; sie
stellte sich als eine abgeplattete Geschwulst von 4-5 cm Durchmesser
dar, die auf dem aufsteigenden Unterkieferaste lag und sich so weit
nach hinten erstreckte, dass das Ohrlappchen abgezogen erschien. Kon-
sistenz hart, Oberflache leicht hockerig. Die ubrigen Speicheldrusen,
sowie die Lymphdrusen waren intakt, ebenso die Hoden. Innere Or-
gane und Blut normal. Syphilis nicht vorhanden.
Pat. bekam in taglich steigender Dosis Solutio arsenicalis Fowleri.
Er kam aber nur bis 14 Tropfen, weil er einen akuten Ausschlag bekam.
Nach 2 Monaten war die Thranendrusengeschwulst der rechten Seite
deutlich verkleinert, wahrend sie auf der linken unverandert blieb.
Auch die Parotisgeschwulste, namentlich die rechte, waren erheblich
kleiner geworden. Ein zweiter Versuch der Arsenikkur musste aber-
mals abgebrochen werden, weil Pat. unter Schuttelfrost einen Ausschlag
bekam und abmagerte. Im Mai 1891, also 14 Monate nach der ersten
Vorstellung, konstatierte Fuchs ungefahr denselben Befund wie das erste
Mai. Samtliche Anschwellungen waren wieder ungefahr zur ursprung-
lichen Grosse herangewachsen. Sie waren aber auch jetzt indolent,
1 Gleichzeitige Erkrankung der Thranendriisen und der Paroddcn. Beitragc zur
Augenheilkunde. Heft III, 1S91.
2 H}"perplasie lymphatique des glandes lacn*males ct salivaircs. Annales d oculisdque
1S89.
148 Medical Classics
hart, nirgends mit der Umgebung verwachsen, so dass sie ganz frei
bevveglich erschienen. Das Allgemeinbefinden war gut. — Bei der ersten
Vorstellung des Kranken excidierte Fuchs ein kleines Stiickchen von
demjenigen Teil der Thranendriise, der sich am meisten unter der
oberen Uebergangsfalte hervordrangte. Bei der Untersuchung dieses
Stiickchens fanden sich, in das kaum veranderte submukose Gewebe
der oberen Uebergangsfalte eingebettet, grossere und kleinere Knoten,
welche den Bau von Lymphomen zeigten. Die meisten waren gegen
das umgebende Gewebe scharf abgegrenzt; sie bestanden aus dicht
gedrangten, einkernigen Zellen, deren Kerne rund oder ein wenig oval,
stark granuliert und mit den angewendeten Farbemitteln intensiv
gefarbt waren. An manchen Kernen erkannte man das sehr sparliche,
siegelringartig angeordnete Zellprotoplasma; an den meisten Kernen war
aber eine deutliche Protoplasmahiille nicht zu erkennen. Zwischen den
zelligen Elementen befand sich kein deutliches Reticulum, sondern eine
fast homogene Zwischensubstanz. Einzelne diinnwandige Blutgefasse
fanden sich im Inneren der Knoten; nirgends eine Spur von Zerfall,
noch von epitheloiden oder Riesenzellen. Elemente der Druse wurden
nicht gefunden.
Die Krankengeschichte des Falles von Haltenhoff ist in Kiirze
folgende.
rzjahriges Madchen, fruher wegen phlyktenuliirer Conjunctivitis in
der Augenklinik behandelt. Vor 4 Monaten entwickelte sich all-
mahlich, ohne bekannte Ursache, ohne Fieber, ohne Beschwerden eine
Anschwellung der oberen Augenlider, vor den Ohren und unter den
Kieferwinkeln, u. z. zuerst am rechten, dann am linken Auge und dann
an den anderen Stellen. — Gut entwickeltes Kind, von etwas blassem
Aussehen, sonst gesund. Symmetrische Vorwolbung der ausseren
Halfte der oberen Augenlider durch eine unter der Lidhaut sitzende,
unbewegliche Geschwulst; keine Rotung, kein Oedem, keine Gefiiss-
Ektasieen. Die Haut iiber dem Tumor verschiebbar; der Tumor selbst
glatt, hart, vollig schmerzlos; er entspricht der Lage nach der Thranen-
driise. Wird das obere Augenlid umgestiilpt, so erscheint die Ueber-
gangsfalte durch einen rotlichen Tumor hervorgedrangt. Conjunctiva
am Bulbus im iibrigen intakt. Beide Parotiden in ihrer ganzen Aus-
dehnung zu indolenten, fast brettharten Tumoren angeschwollen, (p.
620) die dem Kinde ein, dem Bilde des Mumps ahnliches, Aussehen
geben. Auch die Submaxillardriisen sind in symmetrische Geschwiilste
Erkrankung der Driisen 149
von ahnlicher Beschaffenheit umgewandelt. An den Sublingualdrusen
keine Veranderung nachweisbar. Keinerlei Lymphdriisenschwellungen.
Innere Organe gesund. Mandeln etwas vergrossert, die Pharynxschleim-
haut etwas geschwollen. Die Zahne intakt, die Gingiva und Mund-
schleimhaut von normalem Aussehen. Nach Angabe der Mutter soil
das Kind ofter husten und sich schnauzen; der Nasenschleim sei ofter
ubelriechend. Zur Zeit besteht ein geringfugiges Eczem am Nasenein-
gang. — Speichel- und Thranenabsonderung nicht vermehrt. Hamo-
globingehalt des Blutes (nach Gowers) 85%. Der Patientin wird ausser
roborierender Diat und Bewegung in frischer Luft Jodeisensyrup ver-
ordnet. Schon nach 14 Tagen ist eine Volumsabnahme an den Gesch-
wulsten bemerkbar. Nach mehr als einem Jahre war das Madchen von
bluhendem Aussehen. Die Submaxillardrusen sind nicht mehr zu
fiihlen, dagegen erscheinen die Parotiden noch etwas starker als normal.
Die Thranendrusen fuhlt man gerade noch dicht am Orbitalrand.
Ich habe die zwei Falle von Fuchs und Haltenhoff ausfuhrlicher
wiedergegeben, weil sie fiir die Charakteristik des vorliegenden
Krankheitsprozesses von Bedeutung sind. Wenn auch im Fall
von Haltenhoff kein histologischer Befund vorliegt, so stimmt er
doch klinisch mit den anderen zwei en so vollig iiberein, dass wir
annehmen durfen, es handle sich in alien drei Fallen um denselben
Prozess. Der Fall von Haltenhoff ist insofern besonders wichtig,
weil hier innerhalb Jahresfrist die fast vollstandige Riickbildung
der Geschwiilste konstatiert wurde.
Ausser den angefuhrten finde ich noch zwei Falle in der Litte-
ratur, die h'ochst wahrscheinlich auch hierher gehoren. 1 Den
einen Fall von Reymond 2 kenne ich nur nach einem Referat:
Bei einem 57 jahrigen Mann bestand seit 2-3 Jahren beiderseits
eine Anschwellung an den oberen Augenlidern, in der Parotis-
gegend und an den Achseldriisen. Die Geschwulst der Orbita
wurde exstirpiert; die mikroskopische Untersuchung erwies lym-
pholdes Gewebe, das an einzelnen Stellen Zeichen amyloider De-
generation erkennen Hess. Der zweite Fall wurde als Sarkom der
1 Nachtraglich teilt mir Herr Professor Fuchs mit, dass er in der letzten Zeit noch
zwei and ere dem ersten analoge Falle, nur leichterer Art beobachtet babe. Die Ansch-
wellungen nahmen nach Monaten unter Arsengebrauch ab. Leukamie war in k einem
der Falle verhanden.
5 Arch, d’ophthalmologie VI, 23.
Medical Classics
150
Thranendriisen im Jahre 1889 von Adler in der Gesellschaft der
Aerzte zu Wien vorgestellt. 1
Ich teile die Krankengeschichte im Auszug mit.
yojahrigerMann, hat ausser Pneumonie und Dysenterie keine Krank-
heiten durchgemacht, war auch nicht sy^philitisch. Vor einem Jahre
bemerkte er beiderseits (p. 621) in der Gegend der Thranendruse das
Auftreten von Geschwulsten, die allmahlich bis zur jetzigen Grosse
wuchsen. Befund am 3. April 1889: Am oberen ausseren Rande beider
Augenhohlen ziemlich symmetrisch stehen circa 3^ cm lange, 16 mm
breite Geschwulste; der rechtsseitigen sitzt noch ein erbsengrosser
Hocker auf. Der Rand der Geschwulst setzt sich mehr nach aussen
und abwarts ins Lid fort. Die Geschwulste sind knorpelhart, von
hockeriger Oberflache, nicht schmerzhaft; sie lassen sich unter der Lid-
haut, jedoch nicht gegen den Orbitalrand verschieben und sitzen an der
Orbitalwand fest. Die Lidspalten in alien Dimensionen verengert, von
3eckiger Form mit der Spitze nach oben. Im ausseren Abschnitt des
linken oberen Augenlides Ektropium. Beim Umstulpen des Oberlides
bemerkt man, dass die Conjunctiva im Bereich der Uebergangsfalte
degeneriert und teils von Wucherungen in der Grosse von Trachom-
kornern, teils von hahnenkammartigen Excrescenzen besetzt ist. Con-
junctiva bulbiet tarsi normal. Seit3Monaten bmerkt Pat. ausserdem
verschiedene Drusenanschwellungen. Zur Zeit sind zu harten Knollen
angeschwollen die Cervical-, Praeauricular- und Submaxillardrusen.
Seit 6 Wochen Heiserkeit, seit 3 Wochen eine „Hervorragung“ am
harten und weichen Gaumen. Im Rachenraume eine so bedeutende
Schwellung, dass die laryngoskopische Untersuchung unmoglich ist.
Die Untersuchung eines exstirpierten Teiles der Conjunctiva ergab ein
„kleinzelliges Sarkom." Es wurde angenommen, dass ein primates
Sarkom der Thranendriisen vorliege mit allgemeiner Sarkomatose.
Aus diesem Grunde wurde von jedem operativen Eingriff abgesehen
und eine Arsenkur eingeleitet (Tinct. Fowleri bis 10 Tropfen taglich).
Nach 6 Wochen trat eine sichtliche Besserung ein. Die Heiserkeit
verschwand, die Schwellung am Gaumen nahm ab, die Geschwulste
der Thranendriisen verkleinerten sich zusehends, so dass sie nur mehr
2 cm lang und 11 mm breit waren. Die mikroskopische Untersuchung
eines abermals excidierten Stuckchens der erkrankten Conjunctiva bes-
tatigte die fruhere histologische Diagnose; es wurde aber nun, mit Riick-
1 Sitzung vom 17. Mai 1889. Siche Wiener klinische Wochenschrift .1889, S. 42a.
Erkrankung der Driisen 15 1
sicht auf den Erfolg der Arsenbehandlung, ein Lymphosarkom resp.
malignes Lymphom angenommen. Mitte September 1892, also fast 4^
Jahre nach Beginn der Erkrankung, ist der Kranke einer brieflichen
Mitteilung des Herrn Primararzt Dr. Adler zufolge vollkommen geheilt.
Er nimmt noch Arsen.
Die beiden Falle von Reymond und Adler unterscheiden sich
von den friiheren wesentlich durch die Mitbeteiligung der Lymph-
driisen. Es kann daher die Frage entstehen, ob diese Falle iiber-
haupt hierher gehoren; ein Zweifel in dieser Richtung scheint um
so eher berechtigt, als die Erkrankung der Speicheldrusen bei
Reymond und Adler ganz in den Hintergrund tritt. Fuchs
zweifelt iiberhaupt daran, dass im Falle von Reymond die Paro-
tiden miterkrankt gewesen seien; er glaubt, dass die Lymphdrusen
der Praauriculargegend einen Parotistumor vorgetauscht hatten.
In dem Falle von Adler wird der Speicheldrusen gar nicht Erwah-
nung gethan; gleichwohl konnen massige Anschwellungen unter
den intumescierten Praauricular- und Submaxillardriisen der Beo-
bachtung entgangen sein. Ich mochte an diese Moglichkeit
denken, weil im Adler’schen Falle eine Gruppe von Drusen, die
zum Typus der Speicheldrusen gehoren, sicher (p. 611 ) intu-
mesciert waren. Ich meine die Gaumendriisen. Die am harten
und weichen Gaumen bestehende „Hervorragung“ kann ich we-
nigstens nur so deuten; sie entspricht auch dem Verhalten der
Gaumendriisen in meinem Falle.
Eine auffallende Aehnlichkeit mit den fruheren haben die zwei
Falle in Betreff der Erkrankung der Thranendrusen. Der kli-
nische Verlauf, namentlich die Gutartigkeit des Prozesses, die
symmetrische Entwicklung stimmen vollig uberein. Auch der
histologische Befund widerspricht nicht der Annahme eines gleich-
artigen Prozesses.
Die Erkrankung der Thranendrusen ist in unseren Fallen nicht
nur die konstanteste Erscheinung; sie ist auch diejenige, welche
zuerst auftritt. Wir finden in den Krankengeschichten die zwei-
fellose Angabe, dass zuerst die Thranendrusen anschwollen und
spater erst in wechselnder Reihenfolge die anderen Anschwel-
lungen auftraten. Es scheint also, dass die Thranendrusen den
ersten und vornehmlichsten Angnffspunkt des Krankheitserregers
152 Medical Classics
abgeben. Es ware daher a priori auch die Moglichkeit einer
isolierten Erkranknng der Thranendrusen zuzugeben. Wir finden
nun in der Litteratur in der That mehrere Falle von Erkrankung
der Thanendrusen allein verzeichnet, welche nach meiner Mein-
ung hierherzuzahlen sind. Ich sehe von den in den Lehrbiichern
haufig wiederkehrenden Angaben von jjHypertrophieen" der
Thranendrusen ab; ebenso von mehrfachen kasuistischen Mit-
teilungen, die nur eine unsichere Deutung zulassen. Von den
mir zuganglichen Fallen mochte ich nur drei anfuhren. Vor allem
den genau beobachteten Fall von Arnold und Becker 1 aus dem
Jahre 1872.
33 jahriger Muller, hereditar nicht belastet, bis zum 19. Lebensjahre
gesund. Im 20. Lebensjahre wurde er von einer Entzundung beider
Augen befallen, die er auf die Einwirkung des Staubes in der Muhle
zuruckfuhrt. Die Augenentzundung hielt bis zum heutigen Tage in
wechselnder Intensitat an und veranlasste ihn wiederholt, arzdiche
Hilfe zu suchen. Seit dem 30. Lebensjahr soil der Exophthalmus
bestehen. 1. Februar 1871 Aufnahme in die Heidelberger Augen-
klinik. Beide Augen waren stark aus der Orbita hervorgetrieben, ihre
Achsen convergierten nach unten, ihre Beweglichkeit jedoch nach keiner
Seite ganz aufgehoben. Das obere Augenlid war an beiden Augen stark
ausgedehnt und konnte so gut wie gar nicht gehoben werden. Con-
junctiva in der ganzen Ausdehnung gleichmassig gerotet, stark secer-
nierend; am unteren Rande der rechten Cornea Gefassentwicklung.
Starke Lichtscheu. Betrachdiche spontane Schmerzen waren nicht vor-
handen. Als Grund des Exophthalmus Hess sich in beiden Augen-
hohlen eine im oberen ausseren Winkel derselben gelegene, rundliche,
mehr als taubeneigrosse, (p. 623) derbe, nicht pulsierende und bei Druck
nicht schmerzhafte Geschwulst mit glatter Oberflache erkennen. Die
Geschwulst hinter dem rechten Auge war betrachtlich grosser als die
linke. Ein Zusammenhang mit dem Bulbus bestand nicht. — Es wurde
eine Hypertrophie der Thranendrusen angenommen und die Exstirpa-
tion beider Tumoren durch einen parallel mit dem oberen Orbitalrande
gefuhrten Schnitt ausgefuhrt. Anfangs Juni 1872 haben beide Bulbi
normale Lage und Beweglichkeit. Der Tumor ist nicht recidiviert.
Die Conjunctiva an beiden Augen ist sammetartig aufgelockert und
leicht injiciert, die Conjunctiva bulbi netzformig injiciert. Keine Spur
1 Doppelscidgcs, symmetrisch gelcgcncs, Lymphadenom der Orbita. Grafe’s Archiv.
XVIII, a.Abt 56.
Erkrankung der Driisen 153
von Trachomkornern. Vermehrte Sekretion. Sehscharfe normal. —
Am 9. November 1872, also if Jahre nach der Operation, sind die
Tumoren nicht recidiviert.
Die von Prof. Arnold vorgenommene Untersuchung ergiebt,
dass sich der Tumor im wesentlichen aus lymphatischem Gewebe
zusammensetzt. Dichte Anhaufungen lymphoider Elemente,
welche in ein zartes Reticulum eingebettet und gegen die Nach-
barschaft scharf abgegrenzt erscheinen, ahmen vollstandig den
Typus von Lymphfollikeln nach. Sie liegen in einem mehr
gleichartig angeordneten, diffusen lymphatischen Gewebe. Stel-
lenweise finden sich starkere Bindegewebszuge. Arnold nimmt
keinen Anstand, die Geschwiilste als eingentliche Lymphade-
nome, d. i. Neubildung lymphatischen Gewebes, zu deuten. In
Bezug auf den Ausgangspunkt derselben spricht er nur Vermu-
tungen aus. Zur Annahme einer echten Heteroplosie, der Ent-
wicklung lymphatischen Gewebes aus dem Bindegewebe der Or-
bita, kann er sich nur schwer entschliessen. Viel wahrscheinlicher
erscheint es ihm, dass an der betreffenden Stelle im Bindegewebe
der Orbita normalerweise oder bei einzelnen Individuen prafor-
miertes, lymphatisches Gewebe liege, das hier den Ausgangspunkt
der Geschwulst abgegeben habe. Dies sei aber nur Hypothese,
da der thatsachliche Nachweis eines derartigen praformierten
Gewebes zur Zeit fehle.
Nur sehr sparliche Aufzeichnungen konnte ich leider liber die
anderen zwei Falle finden. Der eine wurde mit wenigen Zeilen
von Korn 1 im Jahre 1869 mitgeteilt, und zwar unter Bezugnahme
auf einen von Horner publicierten Fall von beiderseitiger, akuter
Thranendriisenentzundung. Der Fall betrifft eine Cigarrenar-
beiterin, die seit 4 Monaten an einer Anschwellung der Thranen-
drusen litt. Aus der der Mitteilung beigegebenen Abbildung geht
hervor, dass es sich um eine symmetrische, in der Thranendru-
sengegend gelegene Geschwulst handelte, welche genau so, wie in
den anderen Fallen, die aussere Halfte der Uebergangsfalte weit
nach unten drangte.
Den anderen Fall von Power 1 kenne ich nur aus Referaten.
1 Klinische Monatsblatter fur Augenhdlkunde. 1S6S, Mil, iS;.
* Transaction of the ophthalm. 18S7, p. 109.
Medical Classics
i-54
(p. 624) Ein 14 jahriger, im ubrigen gesunder Knabe litt seit
einem halben Jahre an einer Anschwellung beider Thranendrfisen.
Nachdem Medikamente erfolglos blieben, wurde die linke Thra-
nendrfise exstirpiert. Die mikroskopische Untersuchung ergab
eine Hypertrophie des interstitiellen Gewebes, wahrend sich an
der Drfisensubstanz keine auffalligen Veranderungen fanden.
Die mangelhaften Daten uber die zwei zuletzt angeffihrten
Falle gestatten sicher nicht, dieselben ohne Weiteres mit dem
Beckerschen in eine Parallele zu stellen und damit unseren frfi-
heren Fallen anzureihen. Immerhin gehoren sie insofern hierher,
als es sich um eine chronische, symmetrisch auftretende Gesch-
wulstbildung im Bereich der Thranendrfisen mit gutartigem Char-
akter handelt. Dagegen stehe ich nicht an, den Becker ’schen
Fall trotz der isolierten Erkrankung der Thranendrfisen den frfi-
heren direkt an die Seite zu stellen.
Wahrend wir demnach Beobachtungen fiber eine isolierte Er-
krankung der Thranendrfisen nach dem beschriebenen Typus
verzeichnet finden, suchen wir vergebens nach ahnlichen Beob-
achtungen, die sich auf die Speicheldrfisen allein unter Ausschluss
der Thranendrfisen beziehen. Weder in den Lehrbfichern, noch
in den einschlagigen Monographieen finden wir diese Affektion
angedeutet. Die grundlegende Arbeit von Billroth 1 fiber die
Speicheldrusengeschwfilste, die spatere ausgezeichnete Arbeit von
Kaufmann 2 fiber die Parotis-Sarkome und eine jfingst erschienene
Arbeit von Nasse 3 enthalten keine einzige Beobachtung, welche
hieher zu beziehen ware. Es muss auch auffallen, dass mit Aus-
nahme meines Falles alle hier angeffihrten Beobachtungen von
Ophthalmologen herrfihren.
Ich mochte es nicht unterlassen, hier auch noch einige andere
Beobachtungen anzufuhren, welche sich auf die gleichzeitigen Er-
krankungen der Thranen- und Speicheldrfisen resp. Lymphdrfisen
beziehen, aber ausser dieser einen Aehnlichkeit mit unseren Fallen
wenig gemein haben. Zunachst ein von Gordon Norrie 4 mit-
1 Beobachtungen fiber Geschwfilste der Speicheldrfisen. Virchow’s Archiv X\ r II, 357.
*Das Parotis-Sarkom. Arch. f. klin. Chir. XX\ 1 , 672.
•Die Geschwfilste der Speicheldrfisen und verwandte Tumoren des Kopfcs. Arch. f.
klin. Chir. XXXXIV, 233.
4 Centralblatt f. Augenheilk. 1890, 223.
Erkrankung der Driisen 155
geteilter Fall von akuter Entziindung beider Thranendrusen im
Gefolge einer epidemischen Parotitis bei einem 11 jahrigen Mad-
chen, den der Autor wohl mit Recht als echten Mumps der
(p. 625) Thranendriise auffasst. Dann berichtet Galezowski 1 *
liber einen Fall von akuter Entziindung der Thranendrusen,
welchen er bei einer 40 jahrigen Frau beobachtete; die Erkrank-
ung war von einer Schwellung der Praauricular- und Submaxillar-
Lymphdriisen begleitet. Ferner teilt Scheffels 5 einen Fall von
doppelseitiger, nicht eitriger, fieberlos verlaufender Dakryoade-
nitis mit. Die Affektion war nicht schmerzhaft. Gleichzeitig
waren auch die submaxillaren Speichel- und Lymphdrusen zu
kinderfaustgrossen Tumoren angeschwollen ; ausserdem fanden
sich noch anderwarts Lymphdriisenschwellungen und eine Ver-
grosserung der Milz. Parotis und Praauriculardriisen waren un-
verandert. Binnen 13 Tagen gingen die Anschwellungen nach
Jodkaliumgebrauch zuriick. Einen Fall von akuter, indolenter
und ohne Fieber verlaufender Anschwellung beider Thranen-
drusen teilt auch Horner 3 4 mit. Auch hier ging nach Jodkalium-
gebrauch binnen 3 Wochen die Anschwellung zuriick. Doch
fehlten begleitende Erscheinungen von seiten der Speichel- und
Lymphdrusen.
Von chronischen Prozessen, welche mit der uns beschaftigenden
Affektion eine gewisse Aehnlichkeit haben, kommen meines Wis-
sens nur die leukamische Anschwellung und die Tuberkulose der
Thranendriise in Begleitung der gleichnamigen Affektion der
Lymphdrusen vor.
Einen Fall von Leukamie dieser Art hat Gallasch* beschrieben.
Er betrifft ein jahriges Madchen, das an typischer Leukamie
litt und diesem Leiden auch erlag. Ausser der Anschwellung der
Milz, Leber und der Lymphdrusen verschiedener Regionen waren
auch die Thranendrusen, die Parotiden und die Sublingualdrusen
intumesciert. Gallasch fand die Thranendrusen in gleicher Weise
1 Recud 1 d 'ophthalmologic iS$6, 415.
5 Ccntralbl. f. Augcnhdlk. i$90, 136.
3 Kiinische Monatsblattcr 1866, IV, 257.
4 Bddcrsdtigc leukamische Infiltration der Thranendriise. Jahrb. fur Kinderhed,
kunde. 1874, VII 1, Sdtc 82.
i^6 Medical Classics
wie die anderen erkrankten 3 driisigen Organe in einem leuka-
mischen Tumor aufgegangen.
Falle dieser Art scheinen sehr selten zu sein, wenigstens finde
ich keine anderweitige Beobachtung in der Litteratur. Gewiss
ebenso selten dfirfte eine tuberkulose Infiltration der Thranen-
drusen sein. Ich habe einen charakteristischen Fall dieser Art
in Konigsberg beobach tet. Die Erkrankung beider Thranen-
drusen schloss sich an die Entwicklung zahlreicher tuberkuloser
Lymphome der Parotis- und Submaxillargegend (p. 626) an.
Ich teile den Fall seiner Seltenheit wegen ausfiihrlich mit.
Eduard Stein, 20 Jahre alt, Muller aus Rogehnen in Ostpreussen.
Der Yater ist lungenleidend, die Mutter und 3 Bruder gesund. Der
bis dahin stets gesunde, junge Mann bemerkte vor einem Jahre das
Auftreten eines etwa haselnussgrossen Rnotens unter dem Kinn. Bald
kamen neue Knoten in der Nachbarschaft hinzu; sie wuchsen inner-'
halb weniger Wochen verhaltnismassig rasch, nahmen aber dann nur
ganz unmerldich an Umfang zu. So entwickelten sich im Verlaufe von
8-10 Monaten nach und nach die jetzt vorhandenen Anschwellungen
am Gesicht und Hals. Erst vor 4 Wochen bemerkte Pat. die Ent-
wicklung der Geschwulst im linken oberen Augenlid. Beschwerden
hatte er nie davon. — Seit einiger Zeit leidet er an Husten. — Befund am
2. Mai 1889. Kraftig gebauter, gut genahrter Mann von sonst gesun-
dem Aussehen. Beide Submaxillarregionen sind von zusammenhan-
genden Paketen bohnen- bis uber haselnussgrosser Drusen eingenom-
men. (Siehe beistehende Figur D.) Die einzelnen (p. 627) Drusen
sind glatt, von derber Konsistenz; sie lassen sich sowohl gegen einander,
als auch in toto auf der Unterlage in massigen Grenzen verschieben.
Die Haut daruber unverandert, verschiebbar. Das linksseitige Drusen-
paket ist umfangreicher als das rechte und geht ohne Unterbrechung in
eine zweite Gruppe teils zusammenhangender, teils isolierter Drusen in
der Masseter- und Parotisgegend fiber. Die bohnen- bis kirschgrossen
Drusen reichen bis an den Processus zygomaticus und liegen vorwiegend
auf der Fascia parotideo-masseterica. Die Praeauriculardriisen sind
auf Bohnengrosse geschwollen. Eine kleinere Gruppe von Drusen findet
sich in der rechten Parotisgegend. Ein weiterer, zusammenhangender
Zug von ebenso grossen Drusen geht langs des vorderen und hinteren
Randes des Kopfnickers der linken Seite bis an die Clavicula herunter.
Die einzelnen Drusen haben hier uberall dieselbe Beschaffenheit, wie
die zuerst beschriebenen. Ferner finden sich in massigem Grade gesch-
Erkrankung der Driisen 157
wollen und verhartet die Submental-, Cervical-, Axillar-, Cubital- und
Inguinaldriisen. —
Die ausseren 2 Drittel des linken oberen Augenlides sind stark vorge-
wolbt und verbreitert. Dem entsprechend erscheint der betreffende
Fig. D
Abschnitt des Lidrandes defer gestellt, die Lidspalte verengert. Der
tastende Finder findet unter der sonst unveranderten Lidhaut eine circa
1 cm lange, walzenformige Geschwulst von glatter Oberflache und prall
elastischer Konsistenz. Die Geschwulst lasst sich allenthalben bis an
i^8 Medical Classics
den Orbitalrand verfolgen und scheint der oberen Orbitalwand fest
aufzusitzen. An Conjunctiva und Bulbus keine nachweisbaren Ver-
anderungen. Durch Palpation kann man auch an der analogen Stelle
des reehten oberen Orbitalrandes eine flache, derbe, der Orbitalwand
aufsitzende Geschwulst nachweisen, die mit ihrer vorderen Kante
gerade den Orbitalrand erreicht. — Milzdampfung etwas vergrossert,
dock ist die Milz nicht zu tasten. Im iibrigen in den inneren Organen
keine nachweisbaren Yeranderungen. Keine A ermehrung der Letiko-
cyten. —
Es wird zunachst in der Annahme, dass maligne Lvmphomc vorliegen,
ein Yersuch mit der Arseniktherapie (innerlich) gemacht. Da Pat*
trotz ganz allmahlicher Steigerung grossere Dosen nieht vertragt, wird
seinem Wunsche gemfiss nur die Geschwulst am linken Auge entfernt.
i cm langer Horizontalschnitt in der Yerlangerung der Lidspalte,
Durchtrennung der Conjunctiva iiber dem Tumor, Ausschalung der
ganzen Thranendriise mit Pincette und Schere. Naht bis auf den
sussersten Wundwinkel, durch welchen ein schmaler Jodoformgaze-
streifen in die YVundhohle gelegt wird. Heilung unter geringfiigiger
Eiterung. —
Die Hauptmasse der wohl auf das io fache vergrosserten Thranen-
driise besteht aus Granulationsgewebe; in diesen finden sich zahlreich
typische Tuberkel mit Langhans’schen Riesenzellen.
Ahelleicht ist auch ein von Frost 1 mitgeteilter Fall als Tuber-
kulose der Thranendriise aufzufassen. Die Anschwellung dersel-
ben war im Aerlaufe von 9 Monaten zu Stande gekommen. Die
mikroskopische Untersuchung der exstirpierten Druse ergab, dass
die Geschwulst im wesentlichen aus einem granulationsahnlichen,
kleinzelligen Gewebe bestand, das die eigentliche Driisensubstanz
grosstenteils zum Schwund gebracht hatte. An einzelnen Stellen
fanden sich regressive Yeranderungen, an zwei Stellen Verkasung.
(p. 62S) Die zuletzt angefuhrten Falle von akuten und chron-
ischen Erkrankungen der Thranendrusen sind fur uns deshalb
wichtig, weil sie darthun, dass 1) eine beiderseitige Beteiligung der
Thranendrusen bei verschiedenartigen Affektionen vorkommt,
somit fur die uns interessierende Krankheit allein nicht charakter-
istisch ist, 2) dass auch bei anderen akuten und chronischen Er-
krankungen eine gewisse Wechselbeziehung sowohl zwischen
1 Transaction of the ophthalm. 1S87, 109,
Erkrankung der Driisen 159
Thranen- und Speicheldriisen, als auch zwischen den Thranen
und den benachbarten Lymphdriisen besteht. Wodurch diese
Wechselbeziehungen begriindet sind, dariiber kann man nur Ver-
mutungen aussprechen. Vielleicht sind sie dadurch gegeben,
dass sowohl in der Thranendriise als auch in der Speicheldriise,
d. i. in dem sie umgebenden und durchsetzenden Bindegewebe,
normalerweise kleinste lymphatische Elemente vorkommen.
Damit ist die Bildung pathologischen, lymphoiden Gewebes in
diesen Organen einfach erklart; ebenso die gelegentlich vorkom-
mende Beteiligung dieser Driisen bei Leukamie und Tuberkulose
der Lymphdriisen. Mir scheint aber mit dieser Annahme fur die
uns beschaftigende Krankheit noch nicht Alles erklart.
Kehren wir zu den zuerst beschriebenen Fallen zuriick, so
miissen wir daran festhalten, dass es sich um eine chronisch ver-
laufende Erkrankung handelt, welche — soweit die bisherigen Beo-
bachtungen lehren, — in den Thranendriisen ihren Anfang nimmt
und unter Umstanden auf diese allein beschrankt bleibt. Die
weitere Verbreitung des Prozesses erfolgt vorwiegend auf die
Speicheldriisen ; die Beteiligung der Lymphdriisen ist nur in den
Fallen von Reymond und Adler beobachtet worden, falls wir
diese Falle iiberhaupt hierher rechnen. Nun gebe ich gern zu,
dass die histologische Beschaffenheit der Intumescenzen und bis
zu einem gewissen Grade auch der klinische Verlauf zu einem
Vergleich mit den echten malignen Lymphomen notigt; besonders
auch der Umstand, dass in einzelnen Fallen nach Arsengebrauch
ein zweifelloser Ruckgang der Anschwellungen beobachtet worden
ist. Es bestehen aber doch wesentliche Unterschiede zwischen
den zwei Prozessen. Vor allem ist bisher in keinem der Falle
ein maligner Verlauf konstatiert worden. Wenn auch in dem
Falle von Adler lange Zeit hindurch Arsen genommen wurde und
somit der gutartige Verlauf auf das Medikament bezogen werden
konnte, so wurde in meinem und dem Falle von Becker gar keine
medikamentose Behan dlung eingeleitet, im Falle von Halten-
hoff wurde nur Jodeisensyrup verordnet und im Falle von Fuchs
musste die 2 mal eingeleitete Arsentherapie nach kurzer Zeit
abgebrochen werden. Trotzdem (p. 629) trat im Falle von Hal-
tenhoff vollstandige Heilung ein, im Falle von Fuchs keine Pro-
160 Medical Classics
gredienz des Prozesses, in meinem und dem von Becker nach der
vollstandigen Exstirpation kein Recidiv. Es ist mir nicht be-
kannt, dass maligne Lymphome auf Jodeisen so prompt reagieren;
aucb recidivieren nach meiner Erfahrung maligne Lymphome
nach der Operation in kurzer Zeit.
Nach meiner Ueberzeugung handelt es sich hier um einen infek-
tiosen oder parasitaren Prozess im weitesten Sinne des Wortes.
Man ist ja heute vielfach geneigt, auch in der Leukamie und
Pseudoleukamie (maligne Lymphome) eine parasitare Krankheit
zu suchen; eine ahnliche AufFassung durfte fur unseren Krank-
heitsprozess ebenso berechtigt sein. Bei der Frage, ob wir uns
den Krankheitserreger als einen hamatogenen oder einen von
aussen in die Druse eindringenden zu denken haben, mochte ich
mich fur die letztere Annahme aussprechen. 1 Da fur spricht die
Lokalisierung der Krankheit auf die Drusen der Gesichtsregion,
sowie das Fehlen einer Miterkrankung des ganzen Organismus.
Die Verbreitung des Prozesses auf scheinbar vollig getrennte
Organe spricht nicht dagegen, wenn wir uns vorstellen, dass als
Eingangspforten fur den Krankheitserreger die Ausmundungs-
kanale der Thranen- und Speicheldrusen in den Conjunctivalsack
und die Mundhohle dienen und dass der Conjunctivalsack durch
Vermittlung des Thranennasenkanals und der Nasenrachen-
schleimhaut mit der Mundschleimhaut ein Continuum bildet.
Die Beobachtung, dass zuerst die Thranendrusen und dann erst
die tiefer gelegenen Speicheldrusen erkranken, liesse sich dann so
erklaren, dass der Conjunctivalsack die eigentliche Eingangs-
pforte abgiebt, wahrend die Mundhohle erst sekundar von hier
aus infiziert wird. Die Miterkrankung von Lymphdrusen ware
dann auf dem Wege der Lymphbahnen nicht schwer zu erklaren.
In den Thranen- und Speicheldrusen flatten wir uns den Prozess
als einen ascendierenden nach Analogic der Entziindungsvorgange
in der Mamma, den Nieren, den Speicheldrusen vorzustellen.
Dem entsprechend miissten sich im ersten Anfang vielleicht auch
krankhafte Veranderungen in der Conjunctival- und Mund-
schleimhaut finden, die durch denselben Krankheitserreger be-
\ ielldcht yerdcn in kunfdgen FalJen die ncuen Farbungsmethoden von Ehrlich,
Biondi und Hddenhain sowohl fiber den Charakter der Geschwfilste als auch fiber etwaige
Veranderungen im Blut Aufschluss geben.
Erkrankung der Driisen 161
dingt sind. Wenn wir von diesem Gesichtspunkte aus die mitge-
teilten Krankengeschichten durchsehen, so finden wir mehrere
Angaben, dass die betreffenden Schleimhautabschnitte erkrankt
waren, so in meinem (p. 630) Falle und in den Fallen von Becker
und Adler die Conjunctiva, im Fall von Haltenhoff die Nasen-
und Rachenschleimhaut.
Gegen die Auffassung eines ascendierenden Prozesses liesse sich
einwenden, dass dann vorwiegend das eigentliche Drusengewebe
und nicht das interstitielle Gewebe beteiligt sein miisste. Wir
wissen aber, dass das Drusengewebe der Speicheldriisen bei den
verschiedenartigsten Prozessen, sowohl bei Neubildungen als auch
bei entziindlichen Veranderungen sick in der Regel ganz passiv
verhalt oder erst sekundar in Mitleidenschaft gezogen wird.
Sehr lehrreich ist far unsere Frage eine Arbeit von A. Hanau. 1
Dieser Forscher weist zunachst nach, dass die eitrige Parotitis
auch bei akuten Infektionskrankheiten nicht hamatogenen Ur-
sprungs ist, sondern als ascendierender Prozess aufzufassen ist,
der sich von der Schleimhaut der Mundhohle den Ausfiihrungs-
gang entlang in die Druse fortsetzt. Interessant ist es nun, dass
die En tzun dungs err eg er bald die Wand des Ausfuhrungskanals
durchdringen, die Bahn des Ganglumens gewissermassen auf hal-
bem Wege verlassen und nun im lymphgefasshaltigen, den Kanal
umgebenden Bindegewebe in das interstitielle Gewebe der Druse
vordringen. Die Driisenacini selbst sind am Prozess relativ
wenig beteiligt. —
Doch genug der Hypothesen. Ich weiss wohl, dass den von
mir ausgesprochenen Anschauungen sich leicht mit mannigfachen
Argumenten begegnen lasst. Es ware vielleicht einfacher und
bequemer gewesen, sich auf die Mitteilung der Thatsachen zu
beschranken. Wenn ich dariiber hinausgegangen bin, so habe
ich es nur in der Absicht gethan, die Gesichtspunkte anzudeuten,
welche bei der Beobachtung kunftiger Falle ins Auge zu fassen
sind. Hoffentlich gelingt es kunftigen Beobachtern, die Ratsel
zu losen, die uns diese merkwurdige Krankheit stellt.
l Ueber die Entstehung der eitrigen Entzundung der Speicheldriisen. Beitrage zur
path. Anat. von Ziegler und Nauwerck 1889. IV, 487.
1 62 Medical Classics
ERKLARUNG DER ABBILDUNGEN AUF TAFEL IX
(Zu dem Aufsatz: Prof. Dr. J. Mikulicz, Ueber eine eigenartige sym-
metrische Erkrankung der Thranen- und Mundspeicheldrusen.)
Fig. i. Frisches Praparat der linken Submaxillar-Speicheldruse. .
Naturliche Grosse.
Fig. a. Dieselbe Druse auf dem Querschnitt.
Fig. 3. Mikroskopisches Praparat von derselben Druse. Hartnack
ob j- 7-
(Hartung in Flemming’scher Losung, Farbung mit Saffranin.)
EXPLANATION OF THE ILLUSTRATIONS OF PLATE IX
Fig. I. Fresh preparation of the left submaxillary Gland. Natural
size.
Fig. a. The same gland on transverse section.
Fig. 3. Microscopic preparation of the same gland. Hartnack Obj. 7*
(Fixed in Flemming’s solution, stained with saffron.)
Concerning a Peculiar Symmetrical
Disease of the Lacrymal and
Salivary Glands
BY
PROF. DR. JOHANN MIKULICZ
Director of the Surgical Clinic in Breslau
With Plate IX and 5 Woodcuts
the Society for Scientific Medicine at Konigs-
berg 1 a case, which presented a peculiar symp-
tom complex, until then unknown to me.
Both lacrymal glands and all the salivary
glands were changed in a symmetrical manner
into tumors, which pushed themselves markedly forward from
the normal position of these organs and thereby distorted the
physiognomy of the patient in a remarkable way. The tumors
had arisen gradually; they were at the time of examination
of a hard consistency, painless, without trace of inflammatory
signs. Moreover, elsewhere there were present no pathological
changes in the bearer of these tumors.
The interpretation of this disease placed me in the greatest
dilemma, for it occurred nowhere in the list of familiar and re-
corded diseases up to the present time. Also I found not a single
observation similar to mine recorded in the literature. I had
hopes that, perhaps accidently, a second similar case would
come into my hands and thereby I would be enlightened as to
1 Berliner klin, Wochenschrift, 1888, 759.
165
1 66 Medical Classics
the nature of the disease. However, this affection under dis-
cussion appears to be so rare, that I must give up this hope.
Moreover, in the interval, many cases have been reported by
other observers, which have been either entirely like mine or so
similar that they can be included in a review of the disease
process in question.
On this account I have resolved to report my case in detail
today.
HISTORY OF PATIENT
A 4a year old, married farmer, Christof Kalweit of Marienwalde
in East Prussia, had had pneumonia twenty years before; other-
wise he had always been healthy. Seven months previously,
in June, 1887, he noticed that both upper eyelids began to swell;
he had no pain or other trouble, except that with the increased
swelling, opening of the lids was rendered difficult. Later the
palpebral fissure became so much narrowed that it was difficult
for him to see. Soon afterward there appeared under both
angles of the jaw, similar painless swellings, which, as they grew
larger, interfered with eating and speaking. As to the time of
development of other swellings, the patient could tell nothing,
but in any case they first appeared at a later period. Only the
disturbance in the use of his eyes alarmed the patient and brought
him to a doctor, who prescribed for him an internal medicine.
When this had no result, he sought help in the surgical clinic
at Konigsberg.
Condition on January 13, 1888. Strongly built, well nourished
man of an otherwise healthy appearance. No demonstrable
abnormality in the internal organs. Especially the liver, spleen
and kidneys show no changes; urine is free from albumin. Pan-
creas not palpable. Prostate not enlarged. Nowhere does there
appear any swelling of the lymph glands. In the blood there
is no striking change, especially no leukocytosis. Tendon and
superficial reflexes are normal; temperature and pulse normal.
The countenance appears strikingly altered because of the
symmetrical swelling in the region of the upper eyelids, the
parotid and the submaxillary glands. (See the accompanying
illustration, Fig. A.) (See German text.)
Mikulicz’s Disease 167
The upper eyelids hang down so far, especially in their outer
halves, that the palpebral fissure is reduced to a narrow, tri-
angular space, with base formed by the inner two-thirds of the
lower lid. In the outer third the two palpebral margins touch
one another throughout. The patient is unable perceptibly to
raise the upper lid himself, even with strong effort. Conse-
quently the larger, upper and outer segment of the iris and pupil
remain covered by the upper lid. Perhaps in consequence a
convergent strabismus has developed, by which the pupils would
appear in the relatively wide medial part of the palpebral fissure.
Moreover, the outer two thirds of the upper eyelids are arched
forward and laterally as a hemisphere, so that here the middle
fold of the lid appears nearly obliterated. On palpation there
is found under the skin of the lid a small nodulated, firm tumor
of an obliquely oval shape, which can be followed to the edge
of the orbit. The tumor itself is but slightly movable, the
mildly edematous skin of the lid, on the other hand, being easily
displaceable over it. If the upper lid is drawn firmly upward
with the finger, the outer half of the conjunctival fold appears
so far pushed forward by the tumor described, that it reaches
nearly to the edge of the cornea. (Compare the accompanying
illustration, Fig. B.) (See German text.) The conjunctiva
itself appears mildly reddened and somewhat thickened. The
eyeballs are displaced somewhat inward and forward, but other-
wise no pathologic changes are demonstrable. Vision is un-
disturbed.
The parotid region on both sides is occupied by a smooth,
convex, solitary tumor, which corresponds in position exactly
to the situation of the parotid gland; it extends forward to the
middle of the cheek, continued in the niche between the ramus
of the maxilla and the mastoid process and distinctly lifts up
the lobule of the ear. It is firmly elastic in consistency. Its
surface is apparently smooth, the overlying skin slightly movable.
Under each angle of the jaw projects a tumor about the size
of a hen’s egg, covered by normal, movable skin. It is somewhat
displaceable and of a hard consistency; its surface can be recog-
nized in some places to be flattened eminences. The two tumors
almost meet in the midline.
i68
Medical Classics
If the patient opens his mouth, attention is drawn at once to
tumors corresponding to the two sublingual glands. They pre-
sent themselves as two oblong swellings, which, in form and size,
resemble an almond placed on edge, occupy the floor of the oral
cavity on both sides of the frenulum of the tongue. (See Fig.
A, a-a.) They reach to the height of the crown of the teeth and
lie between the tip of the retracted tongue and the row of teeth.
The mucous membrane over the tumor is somewhat swollen.
The palatine glands show a marked enlargement. (See Fig.
C.) (See German text.)
The palate on both sides is occupied by a sharply delineated
swelling of almost the size of a chestnut, extending out over the
edge of the soft palate. Both tumors extend to the alveolar
border, but leave free in the midline a groove of normal appear-
ance \ cm. wide, gradually increasing in v/idth as it extends for-
ward. Anteriorly they reach to the first premolar teeth. The
surface of the swellings appears smooth, the overlying mucous
membrane unchanged, the consistency firmly elastic.
Under the buccal mucous membrane there are found on each
side of the excretory opening of Stenson’s duct, movable nodules,
about the size of a pea (accessory glands). In addition there
lie further forward, in the vestibulum oris under the mucous
membrane, many movable nodules up to pea size.
During the examination, a copious secretion of saliva takes
place, but there is otherwise no sign of salivation existing. On
the oral mucous membrane there is no striking change. Several
teeth are missing, many are carious.
As only the swelling of the lacrymal glands was troublesome
to the patient, in that it made the opening of the palpebral
fissure difficult, a partial removal of these w r as undertaken at
once (February i, 1888). A horizontal incision was made about
i§ cm. long in the direction of the palpebral fissure with a cleft
of the conjunctiva over the most prominent part of the tumor.
The gland was then freed by blunt dissection up to the ridge
of the orbit and the denuded part removed with scissors. The
Mikulicz’s Disease 169
incision was sutured. On each side a mass of the tumor about
n\ cm. long and 1 to i| cm. in diameter was removed, by my
reckoning about § of the entire tumor. Primary healing fol-
lowed. After only a few days the functional result was so
evident that the patient could leave the clinic quite content.
The improvement in the condition did not last long. The
tumors soon appeared again on the eyelids and narrowed the
palpebral fissure almost to the same degree as before the opera-
tion. At the same time the tumors at the angles of the jaw
visibly increased in size. For this reason the patient returned
to the clinic the last of March. All the tumors seemed to have
increased a little in circumference. The swelling of the lacrymal
glands had reached very nearly to the original size. An attempt
at treatment with pilocarpin injection was made in hopes of
obtaining a decrease in the volume of the enlarged glands by
the increased secretion. In spite of profuse salivation, the
result was not satisfactory; therefore this was stopped after
eighteen days treatment and at the urgent desire of the patient
resort was again made to surgery. On the igth of April, with
an incision performed in the same manner as the first time, the
entire lacrymal gland on the right side was extirpated. The
last, deeply situated remaining portion was removed with a sharp
curette. Good healing. On the 1 st of May in the same way
the other lacrymal gland was removed. At the same time the
enlarged submaxillary glands on both sides were dissected out.
They were lying somewhat less firmly in their beds than normal
glands, and permitted enucleation without trouble and with but
a slight amount of bleeding. There was good healing by primary
intention. After ten days the patient was discharged.
Concerning the future lot of the patient, there are only ac-
counts by letter. On July 12, two months after his discharge,
he himself wrote me that he was very well satisfied with his
condition. The swelling of the parotid glands seemed to have
increased, but gave him no trouble. He was not hindered in the
use of his eyes, although he had to work the whole day in the
fields in the sun’s heat. The swellings in the neck (submaxillary
glands) had not reappeared. He felt in very good health.
ijo Medical Classics
On July 25 he was suddenly taken ill with signs of peritonitis
(perityphilitis r), after he had worked all the day before. He died
on the 9th day of the disease. The swellings in the parotid
glands and in the mouth had so retrogressed within a few days
during this sickness that they had almost disappeared before
death.
Concerning the anatomic examination of the specimen re-
moved, I can report the following: The submaxillary glands
which had been removed in toto are most deserving of considera-
tion. First of all it must be brought out that each of the glands,
swollen to the size of a child’s fist, corresponded exactly in relation
to form and segmentation into lobes and lobules to the propor-
tions of the normal gland. The full view and the transverse
section, represented in Plate IX, Fig. 1 & 2, give a true represen-
tation. The tumor shows, in its gross microscopic details, the
normal structure of the gland, only it is increased in mass. An
essential difference in found, however, by the naked eye in the
fresh transverse section in the color and finer structure of the
glandular mass forming the individual lobules. In place of the
finely granular, gray red structure of the normal gland substance,
we see a more homogeneous, pale reddish yellow, amyloid mass
of lesser transparency. Its consistency is decreased and very
fatty. The number of blood vessels seems to be increased only
in the septa, corresponding to the increase in the size of the
organ; the substance of the glands seems remarkably poor in
blood vessels.
The microscopic examination revealed that the main mass of
the tumor was a pretty uniformly arranged tissue consisting
of small round cells. (See Plate IX, Fig. 3) Here and there
the cells lay compactly together; in other places a fine reticulum
is to be seen between them. In single, large cells karyokinetic
figures can be recognized. Imbedded in these small-celled main
masses there appear, partly single and partly in groups, the
apparently unchanged acini of the salivary gland; they are
separated from one another in varying distances by the round
cell tissue.
Mikulicz’s Disease 17 1
Similar relations present themselves in the microscopic ex-
amination of the lacrymal gland; only here the acini were found
less frequently and, it seemed, were entirely lacking in the outer
compressed part of the tumor.
As we try to explain the case just described, we strike on
various difficulties. The disease process exhibits itself clinically
as a slowly arising, huge enlargement of all the salivary and
lacrymal glands, without inflammatory signs and without de-
monstrable general manifestations. The process remains sharply
confined to the region of these glands and involves neither the
neighboring structures nor other organs or tissues. The micro-
scopic examination reveals that the true parenchyma of the
glands plays an entirely passive role. The increase in size is
entirely brought about by a massive, small-cell infiltration of
the interstitial connective tissue.
It is clear that the microscopic findings alone cannot explain
the process. Were a single gland involved in the way depicted,
then we would not hesitate to postulate a true tumor. We
know well enough that even in the salivary glands, the various
tumors of the connective tissue series and, at times, even the
round cell sarcoma occur, arising from the interstitial connective
tissue. But the histologic finding here does not correspond to a
typical round cell sarcoma; moreover the microscopic and still
more the clinical findings speak against the picture of a genuine
sarcoma. I refer to the preservation of the borders of the gland
and particularly the large and small septa between the lobules
of the glands. The histologic nature of the small cell infiltration
corresponds primarily to the properties of a tumor of lymphoid
tissue. Therefore one can think histologically of a lymphoma or
lymphosarcoma . 1 Herewith we resign ourselves to an unsafe
ground, to a field in which clinical observation and histologic
investigation are not yet brought fully into accord and in which
1 1 have indeed regarded the process as belonging to a lymphosarcoma since the first
microscopic examination and with this idea I have communicated the case to Herr Prof*
Fuchs in Vienna*
Medical Classics
172
the nomenclature is still inexact and ambiguous. We could
think first of all of those forms of tumors which arise primarily
from lymph glands or from preformed lymphoid tissue and then
become designated as malignant lymphoma (pseudoleukemia).
Heidenhain 1 has demonstrated lymphatic tissue in the inter-
stitial connective tissue of the salivary glands, namely in the
sublingual glands; therefore there is no objection to the assump-
tion of a primary formation of lymphoma in the salivary gland.
The entire lack of an involvement of the lymph glands and the
spleen — as it accompanies the so-called pseudoleukemia of the
skin, for example — speaks nevertheless against the character of
a malignant lymphoma.
But also the theory of lymphosarcoma, arising occasionally
away from the lymph glands, as in the testicles and in other
organs, is not admissible in my opinion. According to my
knowledge of cases of this kind, we always have to deal with
malignant new growths, which sooner or later metastasize. The
clinical course corresponds to that of typical sarcoma. The
clinical course of our case during the 14 months of observation
was not malignant in spite of the recurrence on the part of the
lacrymal glands; in the last days of life of the patient, the un-
disturbed tumors rapidly decreased in size. If we consider
further that the almost simultaneous appearance of the numerous
seats of disease in the localized, completely separated places
is directly contradictory to our experience with malignant tu-
mor, we must decide to reject the acceptance of such an idea
in our case.
The result of our consideration is therefore purely negative.
Concerning the significance of the process, I can express only
presumptions. But before I express the opinions which I have
made in this direction, I should like to cite cases of other ob-
servers, insofar as they are to be used in reference to my case.
The case most similar to mine has been communicated briefly
by Prof. Fuchs, 3 the lacrymal glands and parotids being diseased
1 Studies of the Physiologic Institute of Breslau, j868, Part 4, p, 116.
3 Simultaneous Disease of the Lacrymal Glands and of the Parotid. Beitrage zur
Angenhdlkunde, r. Ill, 1891.
Mikulicz’s Disease 173
on both sides. In addition there is a case reported three years
ago by Haltenhoff 1 with simultaneous swellings of the lacrymal
glands, of the parotids and the submaxillary glands on both sides.
The case of Prof. Fuchs follows :
A 61 year old, well built man, a glazier by occupation, noticed, five
months before, a swelling of the upper eyelids, and for four weeks
before a tumor in the region of the parotid glands. Presented in the
clinic of Prof. Fuchs in Vienna in March, 1890. Both upper eyelids
were raised in their outer halves by a tumor which lay in the outer,
upper part of the orbit. The anterior border of the swelling felt hard
and uneven; the lids themselves were movable over it. If the lid were
strongly elevated, the conjunctival fold in its outer half appeared
bowed by a brown-red swelling. The bulbs were somewhat displaced
anteriorly, otherwise normal. Vision was undisturbed. — Swelling of
both parotid glands revealing itself as a flattened tumor of 4-5 cm.
in diameter, which lay on the ascending ramus of the mandible and
extended so far backward that the lobule of the ear appeared drawn
away. In consistency hard, surface slightly uneven. The other,
salivary glands, as well as the lymph glands, were normal, likewise
the testicles. Inner organs and blood normal. Syphilis not present.
The patient received. Fowler’s arsenical solution in daily increasing
doses. He had reached only 14 drops when he suffered an acute erup-
tion. After two months the lacrymal gland tumor on the right side
was a little smaller, while that on the left remained unchanged. Also
the swelling of the parotid regions, especially on the right side, had
become considerably smaller. A further trial of the arsenic treatment
had again to be broken off, because the patient got an eruption with
chill and lost weight. In May, 1891, about fourteen months after the
first presentation, Fuchs found nearly the same condition as the first
time. All the swellings had again increased to nearly the original size.
But they were still indolent, firm, nowhere adherent to the surrounding
tissue, so that they seemed freely movable. The general condition
was good. — At the first presentation of the patient Prof. Fuchs excised
a small piece from that part of the lacrymal gland which protruded
most prominently from beneath the upper conjunctival fold. On
examination of this small portion, there appeared imbedded in the
1 Lymphatic Hyperplasia of the Lacrymal and Salivary Glands. Annalcs d ocu-
lisdque, 1SS9.
Medical Classics
174
scarcely changed submucous tissue of the upper conjunctival fold, large
and small nodules which showed the structure of lymphoma. Most
of them were sharply walled off from the surrounding tissue; they
consisted of densely crowded, mononuclear cells, with a nucleus round
or slightly oval, densely granular and highly colored with the stain
employed. In many nuclei the very faint cell protoplasm could be
perceived arranged as a signet-ring; in most nuclei, however, a definite
protoplasmic integument could not be seen. Between the cell elements
there was no definite reticulum, but a very homogeneous intercellular
substance. Single, thin-walled blood vessels were found in the interior
of the nodules; nowhere was there a trace of disintegration or epithelioid
or giant cells. Glandular elements were not to be found.
The history of the case of HaltenhofFs is briefly as follows:
A 12 year old girl had previously been treated in the eye clinic for
a phlyctenular conjunctivitis. Four months before, swelling of the
upper eyelids, in front of the ears and beneath the lower jaw developed
by degrees, without known cause, without fever or complaint, occurring
first in the right, then in the left eye, and finally in the other regions.
She is a well developed child, of a somewhat pale appearance, otherwise
healthy. There is a symmetrical fonvard bulging of the outer halves
of the upper eyelids caused by a fixed tumor under the skin of the lid;
no redness, no edema, no dilatation of blood vessels. The skin over the
tumor is movable; the tumor itself smooth, hard, entirely painless,
corresponding in position to that of the lacrymal gland. If the upper
eyelid is raised, the conjunctival fold appears as if pushed fonvard by a
red tumor. The conjunctiva of the bulb is otherwise normal. Both
parotids are swollen in their entire extent to indolent, very hard tumors,
which gives the child an appearance similar to that of mumps. The
submaxillary glands are likewise converted into symmetrical tumors of a
similar nature. In the sublingual glands no change is demonstrable.
There is no swelling of the lymph glands. The internal organs are
normal. The tonsils are somewhat enlarged, the mucous membrane of
the pharynx slightly swollen. The teeth are intact, the gums and oral
mucous membrane are of normal appearance. According to the state-
ment of the mother, the child often coughs and breathes heavily; the
mucus from the nose is frequently foetid. At present there exists an
insignificant eczema of the nasal orifice. Salivary and tear secretion
are not increased. Hemoglobin of the blood (Gower's method) is 85
Mikulicz’s Disease 175
per cent. Syrup of iodide of iron was ordered for the patient in addi-
tion to a strengthening diet and exercise in the fresh air. After fourteen
days a decrease in the size of the swellings was noticed. More than a
year later the girl had a healthy appearance. The submaxillary glands
are no longer to be felt, but the parotids seem somewhat larger than
normal. The lacrymal glands are to be plainly felt close to the ridge
of the orbit.
I have given the two cases of Fuchs and Haltenhoff in some
detail, because they are of significance for the characteristics
of the disease process in question. Even though in the case
of Haltenhoff no histologic finding is given, it agrees clinically
so completely with the other two, that we can assume that we
are dealing with the same process in all three cases. The case
of Haltenhoff is. especially of importance, because here, within
a year’s time, the very pronounced involution of the sv’ellings
had been substantiated.
Besides those quoted I find two other cases in the literature,
which belong here in the greatest probability. 1 The case of
Raymond 2 * * I know only through a report: A man of 57 years
had had for two to three years a bilateral swelling of the upper
eyelids, the parotid region and of the axillary glands. The tumor
of the orbit was removed; the microscopic examination showed
lymphoid tissue which revealed signs of amyloid degeneration
in some places. The second case was presented as a sarcoma
of the lacrymal glands in the year 1889 by Adler in the Society
of Physicians in Vienna. 5
I give the history of this sickness in abstract.
A man, 70 years old, had had no diseases except pneumonia and
dysentery, and was not syphilitic. A year before he had noticed the
appearance of swellings bilaterally in the region of the lacrymal glands,
which gradually increased to their present size. Examination on April
3, 1S89: — On the upper, outer edge of both orbits there are nearly
1 By way of addition. Prof. Fuchs tells me that he has observed recently two cases
analogous to the first, but of a milder nature. The swellings decreased after a month’s
treatment with arsenic. Leukemia was present in none of the cases.
’Arch. d’ophthalmologie, VI: 23.
’Meeting of May 17, 1SS9. See Wiener klinische \\ochenschrift, 1SS9, p. 422.
Medical Classics
176
symmetrical tumors about 3J cm. long by 16 mm. broad; that on the
right side is a protuberance about the size of a pea. The margin of the
tumor projects outward and downward within the lid. The swellings
are as hard as cartilage, have a nodular surface and are not painful;
they are movable under the skin of the eyelid, but not so near the edge
of the orbit and are fixed on the wall of the orbit. The palpebral
fissure is narrowed in all its dimensions into a three cornered form
with its point uppermost. There is an ectropion of the outer part of the
left upper eyelid. On everting the upper lids one notices that the con-
junctiva is degenerated in the region of the conjunctival fold and in
part is occupied by a protuberance, the size of trachoma granules,
in part by excrescences resembling cocks’ combs. The conjunctiva
of the bulb and tarsi is normal. Also for three months the patient has
noticed various glandular swellings. At the present time the cervical,
preauricular and submaxillar}” glands are swollen into hard nodules.
For six weeks there has been hoarseness, for three weeks a “protrusion”
of the hard and soft palate. In the pharyngeal space there is such a
marked swelling that it is impossible to make an examination with the
laryngoscope. Examination of a small piece removed from the con-
junctiva showed a “small-cell sarcoma.” It was assumed that a primary
sarcoma of the lacrymal gland was present with a general sarcomatosis.
For this reason all operative interference was abandoned and treatment
with arsenic instituted. (Fowler’s tincture, up to 10 drops daily.)
After six weeks an apparent improvement occurred. The hoarseness
disappeared, the swelling of the palates decreased, the tumors of the
lacrymal glands visibly grew smaller so that they were only 2 cm. long
by 11 mm. broad. Again the microscopic examination of an excised
portion of the diseased conjunctiva confirmed the earlier histologic
diagnosis; however, it was now, out of consideration of the result of the
arsenic treatment, regarded as a lymphosarcoma or a malignant lym-
phoma. In the middle of September, 1892, almost four and one-half
years after the onset of the illness, the patient is completely well
according to a communication by letter from the physician-in-chief.
Dr. Adler. He is still taking arsenic.
The two cases of Reymond and Adler differentiate themselves
from the earlier ones essentially by the involvement of the lymph
glands. The question therefore arises as to whether these
cases in general belong here; a doubt in this direction appears
all the more justified in that the disease of the salivary glands
Mikulicz’s Disease 177
was placed entirely in the background in the cases of Reymond
and Adler. Moreover, Fuchs doubted that in the case of Rey-
mond the parotids were involved; he believes that the lymph
glands of the preauricular region had simulated a parotid tumor.
In the case of Adler the salivary glands were not mentioned;
nevertheless moderate swelling could escape observation among
the enlarged preauricular and submaxillary glands. I might
consider this possibility because in Adler’s case a group of glands,
which belong to the salivary type, certainly were swollen. I
refer to the palatine glands. Those “protrusions” of the hard
and soft palate I can only designate as such; they correspond also
to the behavior of the palatine glands in my case.
The two cases have a striking similarity to the earlier ones
in respect to the involvement of the lacrymal glands. The
clinical course, especially the mildness of the process and the
symmetrical devolvement correspond completely. The histologic
findings do not oppose the acceptance of similar processes.
In our cases the involvement of the lacrymal glands is not
the only constant finding; it is the one which first makes itself
evident. We find in the history of the cases the definite state-
ment that first the lacrymal glands swelled and later in a variable
sequence the other swellings appeared. So it seems that the
lacrymal glands serve as -the first and principle point of attack
of the excitant of the disease. For that reason, a priori, we
could concede the possibility of an isolated disease of the lacrymal
glands. And indeed we find in the literature many cases recorded
of disease of the lacrymal glands alone, which, in my opinion,
are to be included here. I disregard the commonly repeated
statement of the text-books of “hypertrophy” of the lacrymal
glands, as well as the numerous reports of case histories which
allow only an uncertain interpretation. From the cases ac-
cessible to me I care to quote only three, first of all the accurately
observed case of Arnold and Becker of the year 1872. 1
A 33 year old miller whose heredity was good, was well until 19 years
of age. When 20 he was attacked by an inflammation of both eyes,
1 Bilateral, Symmetrically Situated Lymphadenoma of the Orbits. Grafe s Archiv.,
XVIII 2 Abt. 56.
178 Medical Classics
which he attributed to the effect of dust from the mill. The inflamma-
tion of the eyes has persisted up to the present time in varying intensity
and caused him repeatedly to seek medical aid. Since the 30th year
of age there has been an exophthalmus. Feb. 1, 1871, he was admitted
to the Heidelberg Eye Clinic. Both eyes protruded markedly from
the orbits, their axes converging downward but their mobility to any
side, nevertheless, not completely abolished. The upper lids of both
eyes were markedly distended and for all practical purposes could not
be raised at all. The conjunctiva in the whole extent was uniformly
reddened, freely secreting; on the lower margin of the right cornea
there was a development of blood vessels. Marked photophobia.
Marked spontaneous pain was not present. As a cause of the exophthal-
mus there could be perceived a swelling in the upper, outer angle of each
orbit, larger than a pigeon’s egg, hard, non-pulsating, not painful on
pressure, with a smooth surface. The swelling behind the right eye
was considerably larger than the left. There was no connection with
the eyeball. — It was assumed to be an hypertrophy of the lacrymal
glands and extirpation of both tumors was performed through an
incision parallel with the upper margin of the orbit. Early in June,
1872, both eyeballs had a normal position and range of motion. The
tumor had not recurred. The conjunctiva of both eyes is loose, like
velvet, and slightly injected, the conjunctiva of the eyeballs retiformly
injected. No trace of trachoma granules. Increased secretion.
Vision normal. — On Nov. 9, 1872, about one and three-fourths years
after the operation, the tumors had not returned.
The examination undertaken by Prof. Arnold shows that the
tumor is composed essentially of the lymphatic tissue. The
compact accumulations of lymphoid elements which appear in a
delicate reticulum and sharply delimited from the surrounding
tissue, are exactly similar to lymph follicles. They lie in a more
homogeneously arranged, diffuse lymphatic tissue. Here and
there are stronger bands of connective tissue. Arnold did not
hesitate to designate the tumor as a true lymphadenoma, that
is, a new growth of lymphatic tissue. But in reference to the
origin of this, he makes only suppositions. It is only with great
difficulty that he can assume it to be a genuine heteroplasia,
the development of a lymphatic tissue from the connective tissue
of the orbit. It appears to him much more probably that at
Mikulicz’s Disease 179
the affected areas in the connective tissue of the orbit there is
lymphatic tissue normally or in certain individuals, which has
formed a point of origin for the tumor. But this is only an
hypothesis, since proof, founded on fact, of such a kind of pre-
formed tissue is lacking at this time.
Unfortunately I can find only very scant records concerning
the other two cases. One was communicated in a few lines by
Korn 1 under a reference to a case published by Homer of a
symmetrical, acute inflammation of the lacrymal glands. The
case concerned a female cigarette maker who suffered for four
months with a swelling of the lacrymal glands. It was seen
from the illustration accompanying the communication that it
was a matter of a symmetrically lying tumor in the region of the
lacrymal glands, which exactly, as in the other cases, presses
the outer half of the conjunctival fold far downward.
The other case of Power, 2 I know only by reference. A boy
of 16, otherwise well, suffered for half a year with a swelling of
both lacrymal glands. After medication without success, the
left lacrymal gland was extirpated. The microscopic examina-
tion disclosed an hypertrophy of the interstitial tissue, while no
striking changes were found in the gland substance.
The incomplete data of the two last quoted cases does not
permit them with certainty to be placed on a parallel with those
of Becker, without any further information, and thereby to be
added to our earlier cases. At any rate, they belong here in
so far as they concern a chronic, symmetrically appearing tumor
formation in the region of the lacrymal glands, benign in charac-
ter. On the other hand, I hesitate to place the case of Becker
directly into the category of earlier cases, in spite of the isolated
affection of the lacrymal glands.
Accordingly, while we find observations recorded on an isolated
disease of the lacrymal glands like the type described, we search
in vain for similar references which relate to the salivary glands
alone, to the exclusion of the lacrymal glands. Neither in the
textbooks, nor in the pertinent monographs do we find this affec-
1 Klinische Monatsblatter fur Augenheilkunde, 1868, VII, 181.
2 Transaction of the ophthalm., 1887, p. 109.
i8o Medical Classics
tion pointed out. The basic work of Billroth 1 on tumors of the
salivary glands, the later, distinguished work of Kaufmann 2 on
sarcoma of the parotid, and a recently appearing work of Nasse 3
do not contain a single observation which could be applied here.
It is also striking that, with the exception of my case, all ob-
servations introduced here originate from ophthalmologists.
I must not neglect to mention several other observations at
this point, which pertain to the simultaneous affection of lacrymal
and salivary glands and their respective lymph glands, but which,
except for this similarity, have little in common with our case.
First a case of acute inflammation of both lacrymal glands follow-
ing an epidemic parotitis in an 11 year old girl, reported by
Gordon Norrie 4 which the author probably correctly took to be
a true mumps of the lacrymal gland. Then Galexowski 5 reported
a case of acute inflammation of the lacrymal glands which he
observed in a woman 40 years of age; the affection was accom-
panied by a swelling of the preauricular and submaxillary lymph
glands. Furthermore, Scheffels 6 reported a case of bilateral,
nonsuppurative dacryadenitis with no elevation of temperature.
The malady was not painful. At the same time the submaxillary,
salivary and lymph glands were swollen to the size of a child’s
fist; moreover, swellings of lymph glands were found elsewhere
and also an enlargement of the spleen. Parotid and preauricular
glands were unchanged. With the use of potassium iodide, the
swellings receded within 13 days. Horner 7 also reported a case
of acute, indolent, fever-free enlargement of both lacrymal glands.
Here also the swelling receded within three weeks with the use
of potassium iodide. Accompanying symptoms on the part of
salivary and lymph glands were lacking.
Of chronic processes which have a certain similarity to the
1 Observations on Tumors of the Salivary Glands, Virchow’s Arch'iv. XVII, 357.
: Parotid-Sarcoma. Arch. f. klin. Chir., XXVI, 672.
1 The tumors of the Salivary Glands and Related Tumors of the Head. Arch. f.
klin. Chir., XXXXIV, 233.
* Centralblatt, f. Augenheilk., 1S90, 223.
5 Recueil d’ophthalmologie, 1SS6, 415.
6 Centralbl. f. Augenheilk., 1890, 136.
■ Klinische Monatsblatter, 1S66, IV, 257.
Mikulicz’s Disease 1B1
affection with which we are concerned, as far as I know, only the
leukemic enlargement and tuberculosis of the lacrymal glands
accompanying the same affection of the lymph glands present
themselves.
Gallasch 1 described a case of leukemia of this type. It oc-
curred in a year old girl, who suffered from typical leukemia
and also succumbed to this malady. Besides the enlargement
of spleen, liver and the lymph glands in various regions, the
lacrymal glands, the parotids and the sublingual glands were
also swollen. Gallasch found the lacrymal glands taken up by a
leukemic tumor in the same manner as the other diseased glan-
dular organs.
Cases of this type appear to be very rare, at least I find no
further observation in the literature. Indeed, a tuberculous
infiltration of the lacrymal gland may be just as rare. I have
observed a characteristic case of this kind in Konigsberg. The
affection of both lacrymal glands followed the development of
numerous tuberculous lymphomata of the parotid and sub-
maxillary region. I give the case in detail because of its rareness.
Edward Stein, 20 years of age, a miller from Rogehnen in East
Prussia. The father suffers from a pulmonary ailment, the mother
and three brothers are healthy. The young man, previously always
healthy, noticed the appearance of a lump about the size of a hazelnut
beneath the chin one year ago. Soon new nodes appeared in the
vicinity; they grew relatively rapidly for a few weeks but then increased
imperceptibly in size. Thus the swelling of the face and neck now
present developed in the course of eight to ten months. Four weeks
ago the patient first noticed the tumor in the left upper eyelid. He
has never been troubled by it. — For some time he has suffered from
cough. — Findings on May 2, 1889. Powerfully built, well nourished
man of an otherwise healthy appearance. Both submaxillary regions
occupied by conglomerate lumps of bean to hazelnut sized glands.
(See accompanying Figure D.) The single glands are smooth, of firm
consistence, displaceable individually as well as in toto within reasonable
limits upon the underlying structures. The skin over them is unchanged
and movable. The left sided group of glands is greater in circumference
1 Bilateral Leukemic Infiltration of the Lacrymal Glands. Jahrb. fur Kinderheil-
kunde, 1874, VII, r, p. 82.
x 8 2 Medical Classics
than that on the right and joins directly with a second group of partly
conglomerate, partly isolated glands in the masseteric and parotid
region. These bean- to cherry-sized glands extend to the zygomatic
process and lie for the most part on the parotidomasseteric fascia. The
preauricular glands are swollen to the size of beans. A smaller group of
glands is found in the right parotid region. An additional continuous
train of glands of the same size runs along the anterior and posterior
borders of the left sternocleidomastoideus down to the clavicle. All the
individual glands here have the same properties as those first described.
In addition, the submental, cervical, axillary, cubital and inguinal
glands are moderately swollen and hardened.
The outer two-thirds of the left upper eyelid is markedly arched
anteriorly and broadened. The affected section of the edge of the lid
appears deeper than its fellow and the palpebral fissure narrowed. The
examining finger finds a cylindrical tumor about a cm. long, smooth
of surface and of elastic consistence beneath the otherwise unchanged
skin of the lid. The tumor can be followed to the orbital edge in all
places and appears to be firmly attached to the superior orbital wall.
No demonstrable changes in bulb or conjunctiva. By palpation at
the analogous spot on the right upper orbital border a flat, firm tumor
attached to the orbital wall may be demonstrated, the anterior edge of
which just reaches the border of the orbit. — Splenic dullness somewhat
enlarged, the spleen, however, is not palpable. No demonstrable
changes in the rest of the internal organs. No increase in leucocytes. —
An attempt at arsenic therapy (internal) was first made, on the
assumption that it was malignant lymphoma. Since the patient could
not tolerate the gradual increase of massive doses at all, the tumor
on the left eye was removed in accordance with his wish. Horizontal
incision i cm. long, prolonging the palpebral fissure, splitting of con-
junctiva over the tumor, extirpation of the whole lacrymal gland with
forceps and scissors. Suture up to the outer corner of the wound,
through which a narrow strip of iodoform gauze was placed into the
cavity of the wound. Healing with slight amount of suppuration. —
The main mass of the lacrymal gland, which was enlarged probably
ten times, consists of granulation tissue; in this are numerous typical
tubercles with Langhans’ giant-cells.
Perhaps a case reported by Frost 1 is also to be regarded as
tuberculosis. Here the swelling had come on during the course
1 Transaction of the ophthabn., 1887,
Mikulicz’s Disease 183
of nine months. The microscopic investigation of the extirpated
gland showed that the tumor consisted essentially of a small-
celled tissue resembling granulations that had caused a large part
of the proper glandular substance to atrophy. Regressive
changes were found in some places, ceseation in two.
The last described cases of acute and chronic diseases of the
lacrymal glands are of importance to us because they show,
(1) that a bilateral involvement of the lacrymal glands occurs
in various affections, that it is not alone characteristic of the
disease in which we are interested, and (a) that a certain alter-
nating relationship exists between lacrymal and salivary glands
as well as between lacrymal and neighboring lymph glands. One
can only surmise as to what this alternating relationship is based
on. Perhaps it is due to the fact that there are normally small
•lymphatic elements in the lacrymal gland as well as in the salivary
gland, that is in the connective tissue surrounding them and
running through them. Thus the formation of pathologic lym-
phoid tissue in these organs is simply explained, likewise the
incidental involvement of these glands in leukemia and tuber-
culosis of the lymph glands. However, it appears to me that
this assumption does not explain everything about the disease
with which we are concerned.
If we return to the cases first described, then we must cling
to the fact that we are concerned with a chronically running
disease, which — so far as the observations up to the present
teach us — begins in the lacrymal glands and under certain cir-
cumstances remains limited to these alone. The further ex-
tension of the process takes place in the salivary glands; the
participation of the lymph nodes has been observed only in the
cases of Reymond and Adler, if we include these cases here.
Now I am willing to admit that the histologic characteristic of
the intumescences and also, to a certain extent, the clinical course
necessitates a comparison with the true malignant lymphoma;
especially also the fact that in some cases after the use of arsenic
regression of the swelling without a doubt has been observed.
But nevertheless there are essential differences between the two
processes. Above all, up to the present, in none of the cases
184 Medical Classics
has a malignant course been substantiated. Even if arsenic was
taken for a long time in Adler’s case and the benign course
there could be attributed to the medication, in my case and
that of Becker no medicinal therapy was introduced at all, in
HaltenhofFs case only syrup of iodide of iron was prescribed
and in Fuch’s case the arsenic therapy introduced on two oc-
casions had to be stopped after a short time. Nevertheless,
in HaltenhofFs case complete cure occurred, in Fuch’s there was
no progression of the process, in that of Becker and in my case
there was no recurrence after complete extirpation. I do not
believe that malignant lymphoma reacts so promptly to iodide
of iron and in my experience malignant lymphoma recurs a short
time after operation.
According to my convictions, we are concerned here with an
infectious or parasitic process in the broadest sense of the word.
Indeed at the present time there is a great tendency to look for
a parasitic infection in leukemia and pseudoleukemia (malignant
lymphoma); a similar idea would be justified in our disease. In
regard to the question as to whether the causative agent is to
be looked upon as hematogenous or as penetrating the gland
from the outside, I am in favor of the latter assumption . 1 The
localization of the disease to the glands of the region of the face,
as well as the lack of a general disease of the whole organism,
speaks in favor of this. The extension of the process to appar-
ently completely separated organs is not to the contrary, if we
keep in mind that orifices of the ducts of the lacrymal glands and
salivary glands in the conjunctival sac and oral cavity serve as
portals of entry for the causative agent and that the conjunctival
sac is continuous with the mucous membrane of the mouth by
way of the naso-lacrymal duct and the nasopharyngeal mucous
membrane. The observation that the lacrymal glands are first
affected and then the deeper lying salivary glands, is thus easily
explained in that the conjunctival sac is the primary portal of
1 Perhaps the new staining methods of Ehrlich, Biondi and Heidenhain in favorable
cases will give some explanation as to the character of tumors as well as some of the
changes in the blood.
Mikulicz’s Disease 185
entry, while the oral cavity is only secondarily infected from
here. The sympathetic affection of lymph glands by way of
the lymphatics then would not be difficult to explain. We should
have to conceive of the process in the lacrymal and salivary
glands as an ascending one analogous to the inflammatory proc-
esses in breast, kidneys and salivary glands. Perhaps in the
beginning, corresponding pathologic changes in the conjunctival
and oral mucous membrane, caused by the same agents ought
to be found. If we regard the case histories reported from this
point of view, we find many statements that the portions of
mucous membrane concerned were diseased, as in my case and
the cases of Becker and Adler the conjunctiva, in HaltenhofFs
case the mucous membrane of the nose and throat.
The objection to the proposition of an ascending infection can
be raised that the proper glandular tissue and not the interstitial
tissue ought to be affected. But we know that the glandular
tissue of the salivary glands, as a rule, remains entirely inactive
and is only involved secondarily in various processes, in neoplas-
tic, as well as in inflammatory changes. A work of A. Hanau 1
is very instructive on this question. This investigator demon-
strates that the suppurative parotitis of acute infectious diseases
is to be regarded not as of hematogenous origin but as an ascend-
ing process, which proceeds from the mucous membrane of the
mouth along the duct into the gland. Now it is interesting
that the inflammatory agents soon penetrate the wall of the
excretory canal, leave the track of the lumen of the passage,
so to speak, at the half-way point, and penetrate the interstitial
connective tissue of the gland via the lymphatic-containing
connective tissue surrounding the duct. The glandular acini
themselves play little part in the process. —
Enough of hypotheses. I well know that the views which
I have expressed easily allow of much argumentation. Perhaps
1 On the Origin of Suppurative Inflammation of the Salivary Glands. Beitrag zur
Path. Anat. von Ziegler and Nauwerck, 1889, IV, 4S7.
i86
Medical Classics
it would be simpler and easier to limit the report to facts. If I
have gone beyond them I have done so only with the purpose
of making clear the points which are to be noted in the observa-
tion of future cases. I hope that future observers will succeed
in solving the riddle which this remarkable disease presents
to us. —
(the end)
MIKULICZ OPERATION— COLECTOMY
To Mikulicz belongs the credit of popularizing resection of a
carcinoma of the intestine by the two stage method. Before
him the single stage resection with primary suture gave a terrible
mortality. If Mikulicz were not so frank and honest in giving
the honor of the invention to another (Block), we could believe
that the idea had been spontaneously born in his own genial
brain. But to this great pupil of the master Billroth, the medical
profession is indebted, as far as treatment of intestinal cancer
goes, because of the careful study and report of this type of case.
Mikulicz gave detailed figures of final results of 106 cases; most
striking is his ability to reduce a mortality of 42.9 per cent follow-
ing resection with primary suture to 12.5 per cent with the two
stage method. A form of two stage resection had been used
previous to this report in cases necessitating rapid completion
of an operation because of the poor condition of the patient.
Mikulicz advised the operation as one of choice in being safer
from every angle; he advanced beyond Block in removing the
mesentery and regional lymph nodes with the involved portion
of intestine. Truly it is a small homage to pay to this great
mind to remember his name at least, in speaking of an operative
procedure which has been of such value.
The article here given in the original form with English transla-
tion by Dr. W. de Rouville and myself is the same one mentioned
in An Exhibit of Important Books , Papers and Memorabilia as
Illustrating the Evolution of the Knowledge of Cancer by Haagensen,
C. D., Amer. J. Cancer, 18: 98, 1933*
Chirurgische Erfahrungen iiber
das Darmcarcinom 1
VON
J. VON MIKULICZ
in Breslau
From Arch. j. klin . Chir. y 6g: 28-47, 1 9°3
EINE HERREN! Die chirurgische Behand-
lung des Darmcarcinoms war schon wiederholt
in unserer Gesellschaft Gegenstand eingehender
Besprechung. Ich brauche nur an den lehr-
reichen Vortrag des Herm Koenig aus dem
Jahre 1890, an die Mittheilungen des Herm von
Bramann aus dem Jahre 1898 und an die eingehende Darstellung
des Herm Koerte zu erinnem, der vor 2 Jahren uber 54 ein-
schlagige Falle berichten konnte. In demselben Jahre hat De
Bovis in der Revue de Chirurgie eine kritische Zusammenstellung
von annahemd 450 chirurgisch behandelten Fallen von Darm-
carcinomen gegeben, vmter einer wohl erschopfenden Beriicksich-
tigung der in der Literatur niedergelegten Erfahrungen. Es
konnte demnach fast uberfliissig erscheinen, den Gegenstand
wieder zur Sprache zu bringen. Und doch wird jeder Chirurg
sowohl nach seinen eigenen Erfahrungen als auch nach der Durch-
sicht der Literatur der Ueberzeugung sein mussen, dass wir noch
weit entfemt von einem Abschluss in der ganzen Frage stehen.
Wenn wir auch heute schon sagen konnen, dass das Darmcarci-
nom eines der dankbarsten Gebiete der Abdominal-Chirurgie
\ortrag, gehalten auf dem 31. Congress der Deutschen Gesellschaft fur Chinirgie.
Darmcarcinom
189
abgiebt, so lassen unsere Resultate doch noch manches zu wiin-
schen iibrig. Sie mussen durch eine VervoIIkommnung der Tech-
nik besser werden; sie mussen auch besser werden durch ein
eingehenderes Studium der klinischen Erscheinungsformen des
Darmcarcinoms; denn dadurch werden wir (p. 29) in die Lage
versetzt, das Leiden friiher zu erkennen und in einem friiheren
Stadium einer chirurgischen Behandlung zu unterziehen. Viel-
leicht werden meine bescheidenen Erfahrungen einen kleinen
Beitrag dazu liefem.
Im Laufe der letzten 11 Jahre kamen in der Breslauer Klinik
106 Falle von bosartigen Darmgeschwiilsten — mit Ausschluss des
Mastdarms — zur Beobachtimg. 5 mal handelte es sich um Sar-
kom, und zwar 3 mal am Dunndarm, 2 mal am Dickdarm.
Einmal lag ein Endotheliom des Colon transversum vor. 100 mal
handelte es sich um Carcinom, welches 5 mal am Dunndarm,
95 mal am Dickdarm sass.
Da das Darmsarkom wohl in den meisten Fallen unter dem-
selben klinischen Bilde wie das Darmcarcinom verlauft, so darf
ich vom practischen Standpunkte aus bei der folgenden Bes-
prechung beide Geschwulstformen zusammenfassen. 1
Dem Geschlechte nach waren es 80 Manner und 26 Frauen.
Ein so starkes Ueberwiegen des mannlichen Geschlechtes (3:1)
kommt meines Wissens in den anderen Statistiken nicht zum
Ausdruck. Bei De Bovis ist das Verhaltniss der Manner zu den
Frauen 54:46.
. In Bezug auf das Alter sind gerade beim Carcinom bei mir alle
Altersstufen vom 2. bis. 8. Lebensdecennium vertreten. Die
jungste Patientin war 16 Jahre alt. Ueber die Vertheilung der
Falle nach Alter und Geschlecht giebt folgende Tabelle Aufs-
chluss:
1 Die unter Umstanden augenfalbgen Unterschiedc im klinischen Verlaufe des Drum-
carcinom s und Sarcoms, namentlich das rascherc ^Vachsthum und das mi tun ter voli-»
standige Fehlen von Stenoscnerscheinungcn beim D arm sa room sind fur den einzelnen
Fall zur Differential diagnose nur mit Vorsicht zu verwerthen, da vrir auch bei den yer-
schjedenen Formen des Darmcarcinoms die grossten Unterschiede nach beiden Rich-
tungen beobachten. Eiine eingehendere Besprechung findet sich in den einschlagigen
Kapiteln des dritten Bandes des Handbuches der praktischen Chirurgie von v. Bergmann,
v. Bruns und v. Mikulicz.
190
Medical Classics
Alter
Fxzuea
Zus&sanc a
Untcr 20
—
I
I
20-29
3
1 !
4
3°~39
10
5
40-49
1 9
3
22
5°~59
23
10
33
60-69
21
6
27
1*79
3
—
3
bbs* Zo
' I
—
7
(P* 3 °) der Hohe des betroffenen Darmabschnittes waren
die Geschwulste folgendermassen vertheilt:
a) Dunndarm 8 Falle (5 mal Carcinom, 3 mal Sarkom).
b) Coecum 20 Falle (19 mal Carcinom, I mal Sarkom).
c) Colon (mit AusschJuss des Coecums und der Flex, sig-
moidea) 40 Falle und zwar:
а) Colon ascendens: 6 Falle.
/?) Flexura hepatica: 7 Falle.
7) Colon transversum: 8 Falle.
(7 mal Carcinom, 1 mal Endotheliom)
б) Flexura lienalis: 12 Falle.
e) Colon descendens: 4 Falle.
?) Colon ohne genaue Localisation 3 Falle.
d) Flexura sigmoidea 31 Falle.
e) Ausgangspunkt unbekannt 1 7 Falle (1 mal Sarkom, 6 mal
Carcinom).
Die angefuhrten Zahlen stimmen mit den anderen z. Th. viel
grosseren Statistiken gut uberein, indem sie ergeben, dass als
Praedilectionsstelle des Darmcarcinoms in erster Linie die
Flexura sigmoidea, in zweiter Linie das Coecum anzusehen sind.
.. 0 gss e tzmassig das Darmcarcinom sich auf die verschiedenen
kbnSh^V d r r Da T S V . ertheilt ’ 50 re S ellos scheint sich der
~ , e er auf 111 den einzelnen Fallen zu gestalten, v/enn vrir
zunachst davon absehen, dass die Hohe des erkrankten Darm-
abschnittes von einem gewissen Einfluss auf die Entwicklung der
ba L.IL 3Urnicht ° pc * rt ' Pa6 ' tcn >
Falls y 0n E»«*emungn, dnige Male, wie in einem
1 2QfGnind von Lymphdrusen gestellt verden konnte.
Darmcarcinom
191
klinischen Erscheinungen ist. Es ist ja bekannt, dass ein Tumor,
wenn er einmal ausgesprochene Functionsstorungen im Darme
hervorruft, nicht gleichartig verlauft, je nachdem er im Diinn-
darm, im Bereiche des Coecums oder in den tieferen Dickdarm-
abschnitten sitzt. Man kann im allgemeinen sagen, dass, je
hoher das Darmcarcinom (p. 31) sitzt, die Erscheinungen urn so
praegnanter und die Storungen um so sturmischer verlaufen.
Wenn wir aber von der Localisation absehen, so kann ein Darm-
tumor an ein und derselben Stelle das eine Mai lange Zeit ganz
latent verlaufen, das andere Mai unklare Intestinalerscheinungen,
das dritte Mai chronische Stenoseerscheinungen, das vierte Mai
plotzlich acuten Ileus verursachen. Wir werden uns uber die
Verschiedenheit des Verlaufes nicht wundern, wenn wir iiberlegen,
dass ein Darmtumor an und fiir sich noch keinerlei Symptome
zu setzen braucht, da er sich in einem Organe festsetzt, das, wie
wir wissen, keine sensiblen Nerven besitzt. Die Beeintrachtigung
der Peristaltik infolge der Infiltration der Darmwand an einer
beschrankten Stelle wird fur den Gang des Verdauungsgeschaftes
auch ohne Belang sein, da die dariiberliegenden Darmparthien
kraftig genug sind, fur das peristaltisch unthatige Darmstuck
vicariirend einzutreten. Erst Complicationen werden das Darm-
carcinom klinisch bemerkbar machen. Diese sind Stenose, Ul-
ceration und Blutung. Die letzten zwei Complicationen werden
sich in der Regel nur bei tief sitzenden Carcinomen, im Bereiche
der Flexur event, des Colon descendens durch Beimengung von
Blut und Eiter zum Stuhle sicher kenntlich machen; die Blutung
auch bei hoherem Sitze, wenn sie profus wird, doch ist das be-
kanntlich gerade beim Darmcarcinom ein seltenes Ereigniss. Als
die constanteste Complication, die fast in jedem Falle fruher oder
spater eintritt, durfen wir die Stenose ansehen, doch ist sie, wie
wir wissen, leider kein Fruhsymptom. Die meisten Carcinome
setzen wohl sehr bald eine Stenose im anatomischen Sinne, aber
diese braucht noch lange nicht zur Stenose im klinischen Sinne,
das ist zur Behinderung der Darmpassage an der betreftenden
Stelle, zu fuhren. Der uber der Stenose liegende Darmabschnitt
compensirt infolge einer stetig zunehmenden Arbeitshypertrophie
lange Zeit die anatomische Stenose und haufig in so vollkommener
192 Medical Classics
Weise, dass keine functionellen Storungen bemerkbar zu sein
brauchen. Wie weit diese Compensation gehen kann, beweisen
am besten jene Falle, in welchen ein bis dahin anscheinend
gesunder Mensch an acutem Ileus erkrankt, als dessen Ursache
man ein schon hochgradig stenosirendes Darmcarcinom findet.
Die klinische Darmstenose tritt eben erst ein, wenn infolge der
dauemden Stauung oberhalb des Darmcarcinoms schwerere
Erscheinimgen von Darmkatarrh sich (p. 32) einstellen, wenn
infolge der ungenugenden Passage durch die stenosirte Stelle der
Darm zu forcirter, krampfartiger Peristaltik gezwungen vird
(Darmsteifung), oder wenn durch ein zufalliges Ereigniss (kleine
Fremdkorper, entzundliche Schwellung) die verengte Stelle plotz-
lich ganz undurchgangig wird. Ich kann es unterlassen, an dieser
Stelle auf die bekannten Erscheinungen der chronischen Darm-
stenose sowie des acuten Darmverschlusses naher einzugehen.
Ich mochte nur betonen, dass das Darmcarcinom haufig auch bei
langerem Bestande symptomlos oder mit nicht characteristischen
Erscheinungen verlaufen kann, dass man daher auch "bei scheinbar
unbedeutenden Storungen der Darmfunction bei der Diagnose ein
Carcinom mit in die Combination ziehen soil, besonders wenn die
Erscheinungen bei einem alteren Menschen auftreten, der bis
dahin sich einer tadellosen Verdauung erfreut hat. Nicht selten
wird man dann durch eine genaue Untersuchung des Abdomens,
durch Aufblahung des Darmes und andere Untersuchungs-
methoden einen palpablen Tumor oder sonst wie Indicien auf
einen Darmtumor finden, und zwar lange, bevor noch schwerere
functionelle Stonmgen aufgetreten sind.
Dass die histologische Form des Carcinoms auch dafur bestim-
mend wirkt, ob eine hochgradige Stenose fruh oder spat eintritt,
darf ich ebenfalls als bekannt voraussetzen. AufFallend sind in
dieser Richtung die Gegensatze, die man zwischen den klinischen
Erscheinungen bei grossen umfanglichen und bei kleinen, durch
die Bauchdecken gamicht palpirbaren Tumoren findet. Ein
grosser, relativ weicher, aber nach dem Darmlumen zu weit
ulcerirter Tumor kann ohne schwere Behinderung der Darm-
passage verlaufen, wahrend ein kleines, auf wenige Centimeter
beschranktes scirrhoeses Carcinom in Folge der starken Schrump-
Darmcarcinom
1 93
fung schon friihzeitig schwere Stenoseerscheinungen bedingen
kann. Namentlich im Bereiche der Flexura sigmoidea sind die
Carcinome der letzten Art nicht selten.
Es ist vielleicht nicht unzweckmassig, die Darmcarcinome nach
ihrem klinischen Yerlaufe oder nach den Stadien, die der einzelne
Fall durchgeht, nach verschiedenen Typen zu gruppiren, wie es
z. B. De Bovis thut, welcher drei Typen unterscheidet:
i. Types de latence absolue ou relative.
i. Types gastrointestinales.
3. Types d’occlusion grave.
(p. 33) Diese Einleitung hat gewiss ihre Berechtigung, da die
meisten Falle wenigstens zwei, vielleicht alle drei Stadien nach
einander durchmachen.
Ich mochte von einem anderen, mehr praktischen Standpunkte
im Yerlaufe des Darmcarcinoms folgende drei Perioden unter-
scheiden :
A) Latenzperiode.
B) Periode der Intialsymptome.
C) Periode der klinisch nachweisbaren Symptome.
A) In Bezug auf die Latenzperiode konnen wir selbstverstand-
lich nur Vermuthungen aussprechen. Die spater angefuhrten
Beobachtungen, nach welchen ein zufalliger Weise im Abdomen
palpirter Tumor, das erste Symptom eines Darmcarcinoms ab-
giebt, Falle, in welchen ohne Prodromalerscheinungen plotzlich
acuter Ileus infolge eines Darmtumors auftritt, sprechen dafur,
dass das Darmcarcinom lange, jedenfalls viel langer als man all-
gemein annimmt, latent verlaufen kann. Auch die Beobach-
tungen, nach welchen ein Kranker mit Darmcarcinom nach der
Colostomie noch mehrere Jahre (ein Fall meiner Beobachtung 4’.
Jahre) bei relativem Wohlbefinden weiterleben kann, spricht in
demselben Sinne. Diese Beobachtungen sprechen auch dafur,
dass das Darmcarcinom entgegen der Anschauung der meisten
inneren Kliniker ein relativ gutartiges Carcinom ist, gutartig
auch deshalb, weil Drusenmetastasen und Metastasen in anderen
Organen in vielen Fallen erst spat auftreten. Wir mussen dies
hervorheben, weil es in hohem Grade fur die Berechtigung der
operativen Therapie beim Darmcarcinom spricht, was heute auch
ig4_ Medical Classics
noch von Seiten der inneren Kliniker zu wenig anerkannt wird.
Wenn ich auf Grund einer Schatzung Zahlen angeben soil, so
mochte ich die Latenzzeit beim Darmcarcinom auf l — 3 Jahre
anschlagen.
B) Was die Initialsymptome betrifft, so konnen sie sich, wie
schon aus den vorangehenden Bemerkungen hervorgeht, ausser-
ordentlich mannigfaltig gestalten. Ich verstehe darunter dieje-
nigen Symptome, welche den Patienten zum ersten Male auf
sein Leiden aufmerksam machen, gleichgiltig ob er alsbald arz-
tlichen Rath aufsucht oder nicht. Nach meinen Beobachtungen
mochte ich zwei Grappen sondern.
a) Falle ohne charakteristische Storungen der Darmpassage;
(p. 34) dahin gehoren 58 der 106 von mir beobachteten Falle, also
mehr als die Halfte und zwar wurden angegeben;
1. 43 mal unklare gastrointestinale Erscheinungen, meist als
Unregelmassigkeit in der Stuhlentleerung beobachtet, indem
entweder Obstipation oder Neigung zur Diarrhoe bestand oder
beide Zustande abwechselten.
2- 9 mal wurde ein Tumor im Abdomen zufalliger Weise be-
merkt, ohne irgend welche Storungen von Seiten des Darmes;
ausserdem wurde noch 12 mal ein Tumor nebcn den fruher ange-
fuhrten unklaren gastrointestinalen Storungen bemerkt.
3. 6 mal waren es locale peritonitische Erscheinungen, die
offenbar von dem ulcerirten zur Perforation fuhrenden Tumor
ausgingen; 5 mal handelte es sich dabei um einen Coecal tumor,
der spater unter dem Bilde einer Perityphlitis mit Abscedirung
verlief, 1 mal trat ohne vorhergehende Prodromalerscheinungen
Perforation in die Blase ein: Cystitis mit Pneumaturie war das
erste allarmirende Symptom.
b) Falle in welchen die Erscheinungen sich in deutlichen Sto-
rungen der Darmpassage ausserten, 48 mal. Darunter 39 mit
Zeichen der chronischen Darmstenose, 5 mit acutem Ileus ohne
Prodromalerscheinungen; 4 Falle konnen als chronischer Ileus,
d. i. als Grenzfalle zwischen chronischer Darmstenose und acutem
Ileus angesehen werden.
C) Die Periode der klinisch nachweisbaren Symptome als ein
besonderes Stadium der Erkrankung anzusehen, ist selbstver-
Darmcarcinom
1 95
standlich etwas ganz willkiirliches, denn das Eintreten dieses
Stadiums hangt ja vor allem davon ab, wann der Kranke Hilfe in
einer klinischen Anstalt sucht. Vielfach, z. B. in alien Fallen
von Ileus wird dieses Stadium mitdem Initialstadium zusammen-
fallen. Immerhin gestattet uns aber eine derartige Gruppirung
zu beurtheilen, wie weit wir die Diagnose zu einer Zeit sichern
konnen, in welcher der Patient sich schon fur so schwer krank
halt, dass er emstlich Hilfe sucht, namentlich von Seiten eines
Chirurgen. Von den 106 Fallen, die bei uns Hilfe suchten, zeigten
84 (80 pCt.) schon ausgesprochen functionelle Storungen von
Seiten des Darms und zwar waren 45 mal Zeichen einer ausges-
prochenen meist schweren chronischen Darmstenose vorhanden,
28 mal acuter Ileus (dazu kommen noch 2 Falle, die wegen Ileus
ausserhalb der Klinik (p. 35) colostomirt worden waren), 1 1 mal
handelte es sich um chronischen Ileus.
Nur 22 mal (20 pCt.) fehlten typische functionelle Darm-
storungen. Der Darmtumor machte in diesen Fallen folgende
Erscheinungen :
1. 7 mal beschrankte sich dies Symptom lediglich auf einen
palpirbaren Tumor im Abdomen.
2. 8 mal waren Zeichen der Perforation verhanden, und zwar
je 1 mal Perforation in die freie Bauchhohle mit Peritonitis, Per-
foration in die Blase, Perforation in den Magen, 5 mal war ein
perityphlitischer Abscess vorhanden.
3. In 7 Fallen lagen auch zur Zeit der klinischen Beobachtung
nur unklare Gastrointestinalerscheinungen vor.
Wir sehen also, dass zur Zeit der klinischen Beobachtung mit
Ausnahme von 7 Fallen immer schwere Erscheinungen vorlagen,
welche die Diagnose eines Darmtumors oder wenigstens eines
stenosirenden oder ulcerirenden Darmprocesses anzeigten. Fur
den Chirurgen war also in diesen Fallen die Diagnose geniigend
sicher gestellt, um die Frage, ob ein operativer Eingriff am Platze
sei oder nicht, zu beantworten. Es wurde mich zu weit fuhren,
hier auf die Schwierigkeiten in der Differentialdiagnose zwischen
dem Darmcarcinom und anderen ulcerirenden und stenosirenden
Processen des Darmes naher einzugehen. Haufig genu g wird sich
der Chirurg mit der allgemeinen Diagnose „Darmtumor oder
zg6 Medical Classics
„Darmstenose“ begnugen mussen, und wenn keinc Contraindica
tionen vorliegen, v/ird schon die Moglichkeit eines Darmcarci-
noms die Berechtigung zu einer Probcincision geben, durch wclche
die weitere Diagnose und die Art der vorzunehmcnden Operation
erst entscbieden werden muss. Insofern ist cine praecise Differ-
entialdiagnose des Grundleidens vor der Operation von gcringer
praktischer Bedeutung. Dagegen mussen wir in ciner Richtung
die klinischen Erscheinungsformen des Darmcarcinoms strcng
auseinanderhalten, namlich je nachdem es unter dem Bilde des
acuten Ileus oder aber der chronischcn Darmstenose, rcsp. anderer
mehr schleichender Symptome in unsere Behandlung kommt.
Auf diesen Punkt haben schon mehrere erfahrenc Chirurgen,
zuletzt Koerte hingewiesen; es wird aber immer noch nicht als
allgemein gultige Regel angesehen, einen Fall von Darmcarcinom
mit acutem Ileus und einen solchen (p. 36) ohne Ileus als zwei
Krankheiten anzusehen, die nicht nur prognostisch vcrschicden
zu beurtheilen, sondern auch in Bezug auf die operative Thcrapie
verschieden zu behandeln sind. Der Kranke mit eincm unter
chronischcn Erscheinungen verlaufenden Darmcarcinom ist
selbst, wenn er in seiner Ernahrung recht herunter gekommen
ist, falls nicht schon ausgedehnte Metastasen, Ascites oder vorge-
schrittene Kachexie vorhanden ist, in der Regel widerstandsfahig
genug, um einen schv/ereren Eingriff, zumal die Radicaloperation
zu vertragen. Die Hauptgefahr, die der peritonealcn Infection,
konnen wir durch die spater zu besprechende zweizeitige Rcsec-
tionsmethode fast mit Sicherheit vcrmeiden. Demgegeniiber ist
ein Carcinomkranker mit acutem Ileus nach jeder Richtung hin
sehr wenig leistungsfahig. Einer grosscn intraabdominellcn Op-
eration, selbst einer technisch noch so giinstig gelegenen Darm-
resection, ist er meist nicht mehr gewachsen. Es wiirde zu weit
fuhren, hier alle Griinde dafiir anzufuhren. Die Statistik zeigt,
dass Ueuskranke Eingriffen, welche die Kranken der ersten Kate-
gorie spiel end uberstehen, meist erliegen. Nur ausnahmsweise
gelingt es einmal, einen derartigen Kranken nach der Resection
durchzubringen. Die 3 von mir operirten Fallc sind sammtlich
gestorben. (Einer hatte allerdings die Hauptoperation, den
ersten Akt der zweizeitigen Resection, gliicklich uberstanden und
starb erst an einer Nachoperation). Selbst die Enteroanasto-
Darmcarcinom
197
mose wird meist ein zu schwerer Eingriff sein. Wir werden uns
daher bei Ileus wegen Darmcarcinoms auf das nothwendige Mini-
mum des Eingriffes beschranken, d. h. zunachst nur die Colo-
stomie ausfuhren, und sofern der Tumor zur Resection geeignet
ist, dieselbe erst in einer zweiten Sitzung, nachdem der xiber-
staute, in seiner Emahrung schwer geschadigte Darm sowie der
Patient sich vollstandig erholt haben, vornehmen.
Nach dem Gesagten bedarf es keiner weiteren Begriindung,
wenn ich von meinen 106 Fallen 23, welche mit acutem Ileus der
Klinik zugefuhrt wurden, von den ubrigen 83 sondere. Unter
den Ietzteren befinden sich auch solche die fruher ausserhalb der
Klinik an acutem Ileus erkrankt waren und nach erfolgreicher
Colostomie bei uns einer zweiten Operation unterzogen wurden.
Beschaftigen wir uns zunachst mit den Ietzteren Fallen, die
mit chronischen Symptomen in unsere Behandlung kamen. Be-
kanntlich (p. 37) stehen uns hier neben der Resection, als Pal-
liativoperationen noch zur Verfiigung: die einfache Colostomie
und die Enteroanastomose mit completer oder incompleter Dar-
mausschaltung. Nicht immer werden wir in der Lage sein, von
vornherein zu bestimmen, ob die Radicaloperation moglich sein
wird, oder ob wir uns auf eine der Palliativoperationen besch-
ranken werden. In diesem Falle wird die Operation als Probe-
incision zu beginnen haben. Ueber die Grundsatze, welche uns
bei der Wahl zwischen Radicaloperation und einer der palliativen
Operationen leiten sollen, sobald einmal die Bauchhohle eroffnet
ist, sind wir im Allgemeinen einig. Immerhin wird es im ein-
zelnen Falle noch sehr von der personlichen Erfahrung abhangen,
ob der Operateur sich noch zu der eingreifenden Radicaloperation
oder zu einer Palliativoperation entschliesst, oder ob er gar die
Bauchhohle unverrichteter Dinge wieder schliesst. Fruher, als
ich in der Regel die einzeitige Resection ubte, entschloss ich mich
nur bei gunstigen allgemeinen und lokalen Bedingungen zur Re-
sektion. Seit ich die ungleich weniger gefahrliche zweizeitige
Methode ube, gehe ich viel weiter. Selbstverstandlich wird,
wenn wir in der Indicationsstellung noch so weit gehen, immer
eine nicht unbetrachtliche Zahl von Fallen ubrig bleiben, bei
denen wir von jeder Operation absehen.
Die 83 Falle von malignem Darm tumor mit chronischen Symp-
xg8 Medical Classics
tomen vertheilen sich nach der Art der eingeleiteten Behandlung
folgendermaassen :
Nicht operirt J 7 l
Probeincision 7 davon + o
Colostomie 6 davon + o
Enteroanastomose mit Darmausschaltung 16 davon + 3
Resection . 37 davon + 11
= + 2 9>7pCt.
Davon einzeitig mit primarer Naht 2 1 davon -r 9
= + 4 2 >9 P Ct
Zweizeidg mit Vorlagerung 16 davon + 2
= + 12,5 pCt
(p. 38) In Bezug auf die unmittelbasen Resultate der ein-
fachen Probeincision und der Palliativoperationen ist nichts Be-
sonderes zu bemerken. Dagegen lohnt es sich, naher auf die
Erfolge der Radicaloperation einzugehen. Es fallt ohne Weiteres
die grosse Ueberlegenheit der zweizeitigen Resectionsmethode
uber die einzeitige mit primarer Darmnaht in die Augen. Bei
dieser eine Mortalitat von 42.9 pCt., bei jener nur 12.5 pCt.
Das Resultat erscheint noch gunstiger, wenn wir beriicksichtigen,
dass die zwei Todesfalle bei der zweizeitigen Methode nicht der
Operation als solcher zur Last fallen. Ein Fall starb 7 Wochen
nach der Operation an Marasmus infolge von Carcinommetas-
tasen; im zweiten Falle war Peritonitis die Todesursache und
zwar infolge der Ruptur des carcinomatos infiltrirten Colon de-
scended, welches mit dem Colon transversum verwachsen war
und bei der Ablosung einriss.
Soweit ich in der Literatur orientirt bin, gilt heute fast allge-
mein noch die einzeitige Resektion des carcinomatosen Darmes
mit primarer Darmnaht als Regel. Die Resultate dieser Opera-
tion sind nun gerade beim Carcinom im Bereiche des Dickdarms
bisher recht wenig befriedigend, gleichgiltig, ob die Darmverei-
nigung nach der alten Methode durch circulare Darmnaht oder
durch seitliche Implantation oder Apposition oder endlich mit
dem Darmknopf bewerkstelligt wird. Ich brauche nur einige
1 Davon ein Fall noch in der Klinik gestorben. Die Operation wurde in der Regel
wegen zu writ fortgeschrittener Cachexie, wegen Metastasen u.s.w. unterlasscn. Etlichc
Male verweigerte der Patient die vorgeschlagcne Operation.
Darmcarcinom
1 99
statistische Zahlen anzufuhren. Von Koerte’s 19 radikal ope-
rirten Fallen starben 7 (3 davon allerdings im Ileus operirt), von
Czerny’s 18 Fallen starben 9, von v. Bramann’s 14 Fallen 6, von
ICroenlein’s 12 Fallen 6. Mit diesen Zahlen stimmt so ziemlich
iiberein die grosse Statistik von de Bovis, welcher 104 Falle aus
zusammenhangenden Serien bekannter Chirurgen zusammen-
gestellt hat. Die Mortalitat betragt 38.4 pCt. De Bovis hat
ferner 51 Todesfalle hach der einzeitigen Resection auch aus
anderen Einzelpublikationen zusammengestellt. 13 mal war Col-
laps, 30 mal Peritonitis die Todesursache. Interessant ist auch
die Thatsache, dass bei den ohne Drainage der Peritonealhohle
Nachbehandelten die Mortalitat 5 hoher war als in den drainirten
Fallen. Die angefuhrten Zahlen sprechen deutlich genug. Die
Todesfalle an Collaps beweisen, dass die Operation fur einen
betrachtlichen Theil der Patienten zu eingreifend war. Die 30
Falle von Peritonitis beweisen, dass in mehr als der Halfte der
Todesfalle das Peritoneum (p. 39) entweder noch wahrend der
Operation inficirt wurde, oder die Peritonitis nachtraglich durch
Insufficienz der Naht entstand. Zweifellos ist die Gefahr der
peritonealen Infection bei dieser Operation, sei es primar, sei es
secundar durch Insufficienz der Naht, enorm gross. Das ist leicht
verstandlich, wenn wir uns die Verhaltnisse vergegenwartigen,
unter welchen die Darmnaht vorgenommen wird. Die Darm-
vereinigung am Dickdarm — von diesem allein sprechen wir hier
— ist an und fur sich wenig verlasslich, nach welcher Methode
wir sie auch immer vornehmen mogen. Die geringere Starke der
Dickdarmwand, die schlechtere Gefassversorgung, die trage Peri-
staltik, infolge deren der eingedickte Koth an der Nahtstelle
stagnirt, geben lange nicht die Sicherheit fiir die primare Verkle-
bung an der Nahtstelle wie beim Dunndarm; dazu kommt, dass
wir beim Darmcarcinom in der Regel nicht normale Darmtheile
mit einander vereinigen. Der zufuhrende Schenkel ist haufig
uberdehnt und infolge dessen schlecht emahrt, haufig ist er auch
paretisch, wodurch die Stagnation und die Unsicherheit der Naht
noch gesteigert wird. Viel hoher, als im Allgemeinen angenom-
men wird, ist die Gefahr der primaren Infection des Peritoneums
durch den eroffneten Darm anzuschlagen. Wenn wir auch noch
200 Medical Classics
so peinlich durch temporare Tamponade das zu resecirende Darm-
stuck von der Peritonealhohle ausschalten, die Verbreitung von
Darmbakterien auf der Serosa selbst in weiter Entfernung lasst
sich dabei doch nicht verhindern. In einer interessanten Arbeit
hat Hans Buchbinder 1 nachgewiesen, dass selbst aus einer fein-
sten Stichoffnung des Darms sich die Bacterien mit grosser Gesch-
windigkeit auf der Oberflache der Serosa verbreiten und zwar
nicht nur auf die unmittelbar betroffenen, sondern auch auf die
benachbarten Darmschlingen. Wir miissen demnach damit rech-
nen, dass bei jeder Magen- und Darmoperation trotz aller Kaute-
len Bacterien in einer gewisscn Menge in die Peritonealhohle
gelangen. Je langer die Operation dauert, desto grosser die
Menge derselben. Nun wird zweifellos in vielen Fallen, wir kon-
nen fast sagen in der Regel, vom Peritoneum ein geringes Maass
von Bacterieninvasion uberwunden; der EfFekt ist die nach alien
Magen- und Darmoperationen beobachtete circumscripte Perito-
nitis, die zu den z. Th. schutzenden (p. 40) Verlothungen in der
Umgebung der Nahtstelle fuhrt. Die Fahigkeit, eine derartige
geringfugige peritoneale Infektion glucklich zu uberwinden, hangt
nun in erster Linie von der Widerstandsfahigkeit des ganzen
Organismus ab. Der an acutem Ileus Erkrankte ist infolge der
Darmintoxation so widerstandslos, dass er selbst ein Minimum
von Infection nicht uberwindet. Aber auch bei der chronischen
Darmstenose, die ja, wie wir wissen, in der Regel das Darm-
carcinom begleitet, befindet sich der Patient im Zustande einer
chronischen Intoxication, durch die er den Darmbacterien gegen-
uber zweifellos auch weniger widerstandsfahig wird. Wir finden
darin eine genugende Erklarung fur die schlechten Resultate der
einzeitigen Darmresektion bei Carcinom. Ich zweifle nicht, ass
auch die haufigen Pneumonien nach diesen Operationen z. Th.
wenigstens auf eine bacterielle Infection vom Peritoneum aus
zuriickzufuhren sind, die lokal wohl glucklich uberstanden wird,
aber auf dem Wege kleiner Lungenembolien zur Pneumonie fuhrt.
Es ist somit kein Zweifel, dass wir eine Besserung der Resultate
nur erzielen konnen, wenn wir
1 Kcpoiraentelle Untersuchungen am lebenden Thier- und Menschendarm. Deutsche
Z«tsainft fur Cmroigie. Bd. <5. S. 458.
Darmcarcinom
201
1. die Operation weniger angreifend gestalten und dadurch
die Gefahr des Collapses verringern, und
2. die peritoneale Infection wahrend der Operation und im
Yerlaufe der Heilung verhindem. Beides erreichen wir durch
die zweizeitige Operation.
Die Idee, die Darmcarcinome durch zweizeitige Operation zu
entfernen, ist keineswegs neu. Noch Ende der 70. Jahre sahen
sich Schede, Gussenbauer, Maydl, v. Volkmann u. A. theils durch
die technische Unmoglichkeit. nach der Resection des Tumors
die Darmenden durch die Naht zu vereinigen, theils weil der
Krafteverfall des Kranken eine rasche Beendigung der Operation
verlangte, gezwungen, dieselbe mit der Anlegung eines Anus prae-
ternaturalis zu beschliessen. Dieser konnte, wenn die Verhalt-
nisse es gestatteten, nachtraglich geschlossen werden. Neben
dieser durch die Nothlage gegebenen zweizeitigen Operation
wurden spater auch andere Combinationen verwendet, so zu-
nachst Anlegung eines Anus praeternaturalis oberhalb der steno-
sirten Stelle, zumal wenn Ileus bestand, in einer spateren Zeit
die Resection mit typischer Darmnaht. Eine allgemein bekannte
Combination ist ferner: zunachst Enteroanastomose mit par-
tieller oder totaler Ausschaltung (p. 41) des erkrankten Darm-
stuckes und in einer spateren Sitzung Exstirpation des Tumors.
Die zwei letztgenannten Combinationen haben zweifellos den
grossen Vortheil, dass sie zunachst den zufuhrenden Darm ent-
lasten und dadurch die secundaren Veranderungen an demselben
beseitigen. Die zweite Operation wird dann innerhalb annahernd
normaler Darmtheile vorgenommen. Eine der Hauptgefahren
aber beseitigen diese zwei Combinationen garnicht oder nur in
unzureichendem Maasse, namlich die der primaren und secun-
daren Infection des Peritoneums. Diese Gefahr nebst alien
anderen wird am besten umgangen durch die zweizeitige Opera-
tion, wie ich sie seit nunmehr 5 Jahren principiell bei alien Dick-
darmtumoren ausube. Sie besteht im Wesentlichen darin, dass
der Tumor wie zur einzeitigen Resection aus alien seinen Ver-
bindungen gelost wird bis auf den Zusammenhang mit dem zu-
und abfuhrenden Darmschenkel. Der so mobil gemachte Tumor
wird vor die Bauchwunde gelagert, diese bis auf die Durchtritt-
202 Medical Classics
stelle dcr beidcn Darmschenkel verschlossen und nun entweder
sofort oder nach Ablauf von 12-48 Stunden der Tumor extra-
peritoneal resecirt. Der resultirende Anus praeternaturalis wird
spater verschlossen.
Dem Princip nach wurde dieses Verfahren meines Wissens
7.uerst von Oscar Bloch in Kopenhagen im Jahre 1892 angewandt.
Er land in einem Falle von Ileus als Ursache desselben einen frei
bewegliehen, in der Flexura sigmoidea sitzenden Tumor. Er
lagerte denselben sammt dem langen Mesosigmoideum vor die
Bauchwand und incidirte den Darm oberhalb der Geschwulst.
Nach Bcseitigung der Ileuserscheinungen fiihrte er extraperitoneal
die Resection aus, welcher nach 4 Monaten der Verschluss des
Anus praeternaturalis durch die circulare Darmnaht folgte.
Bloch empfahl dieses Verfahren zuniichst nur fur Darmtumoren
mit beweglichem Mesentcrium und sprach auch schon damals die
Uebcrzeugung aus, dass die meisten Gefahren der Operation
durch die extraabdominelle Darmresection beseitigt wurden.
Zwci Jahre spater ging er einen Schritt weiter, indem er einen
wenig mobilen Tumor des Colon descendens dadurch genugend
mobilisirte, dass er die Umschlagstelle von Gekroswurzel und
Peritoneum incidirte. Ob Bloch spater noch weiter gegangen ist
und in der von mir geiibten Weise vorging, indem er auch das
Mesenterium primar rcsecirte, ist mir nicht bekannt. Jedenfalls
lag die Idee dazu nicht fern. (p. 42) Es ist klar, dass das ur-
spriingliche Bloch’sche Verfahren, abgesehen von seiner be-
schrankten Anwendbarkeit den grossen Nachtheil hat, dass durch
die Belassung des Mcsenteriums die regionaren Lymphdrusen
unberucksichtigt bleiben. Ausser Bloch haben spater noch an-
dere Chirurgen in vereinzelten Fallen ein ahnliches ^^erfahren
eingcschlagen. So Allingham, W. Edmunds, Hochenegg u. A.
Im Ganzen finde ich bci De Bovis 8 derartige Operationen ver-
zeichnct, die alle mit gunstigem Erfolge endeten. Dass von mei-
nen 16 Fallen nur 2 todtlich verliefen und dass in beiden Tode-
stallen die Operationsmethode an dem ungliicklichen Ausgange
nicht schuld war, habe ich schon friiher erwahnt. Die Operation,
vie sic in meiner Klinik im Laufe der letzten Jahre ausgebildet
worden ist, gestaltet sich des Genaueren folgendermaassen.
Darmcarcinom
203
Es wird der Darmtumor sammt den erkrankten Lymphdriisen
und dem entsprechenden Stuck Mesenterium wie bei der ein-
zeitigen Resection aus alien Verbindungen gelost, sodass er
schliesslich nur noch mit dem zu- und abfuhrenden Darm in
Verbindung steht. Die Ablosung des Mesenteriums muss soweit
geschehen, dass der zu exstirpirende Darmabschnitt ohne starkere
Spanmmg vor die Bauchwand gelagert werden kann. 1 st dies
geschehen, so wird die Bauchwand soweit geschlossen, dass nur
der zum Durchtritt des zu- und abfuhrenden Darmschenkels
nothlige Spalt freibleibt;dieser Spalt darf nicht zu eng sein, damit
der zufuhrende Darmschenkel nicht comprimirt wird. An der
Beruhrungsstelle des Peritoneum parietale mit den heraustre-
tenden Darmschenkeln wird eine Reihe von Serosanahten ange-
legt, die die Peritonealhohle auch an dieser Stelle abschliessen.
Die aussere Haut wird bis an die heraustretenden Darmschenkel
exact vemaht (keine Tamponade). Nun wird die Nahtlinie
sowie die Beruhrungsflache zwischen vorliegendem Darm und
Hautwunde dick mit Zinkpaste bedeckt und daruber steriles Ver-
bandzeug gelegt. Ueber den Wundverband kommt noch ein
grosseres Stuck wasserdichten Stoffes mit einem Schlitz gerade
gross genug, den vorgelagerten Darm heraustreten zu lassen. So
ist schliesslich der zu resecirende Tumor von der Bauchhohle
nicht nur durch die vemahten Bauchdecken, sondern auch durch
den schutzenden Verband getrennt. Fruher habe ich den Tumor
erst nach Ablauf von 12-48 Stunden abgetragen, jetzt thue ich
est meist sofort. In den abfuhrenden Darmschenkel (p. 43) wird
ein dickes Glasrohr eingebunden und an dieses ein dickes Gum-
mirohr befestigt, durch das der Darminhalt nach aussen abfliesst.
Die Bauchdeckenwunde heilt bei diesem Vorgehen soweit sie
vemaht ist, anstandslos per primam. Den bei der Abtragung
des Tumors resultirenden widernaturlichen After verwandle ich
nach 2-3 Wochen mittels meiner Sporenquetsche zunachst in eine
Kothfistel, die spater durch Naht verschlossen wird.
Die Vortheile dieses Verfahrens sind ersichtlich. Die Haupt-
operation ist kurzer als bei der einzeitigen Methode 3 die Infection
des Peritoneums wahrend der Operation wird absolut vermieden,
man kann sie daher einem durch das Leiden heruntergekommenen
Rranken viel eher zumuten. Ein weiterer Vortheil ist der, dass
2 04
Medical Classics
man sie bsi welter Ausdehnung des Tumors oder bei tiefem Sitze,
z. B. am unteren Schenkel der Flexura sigmoidea auch in solchen
Fallen ausfuhren kann, in welchen die primare Darmnaht wegen
zu starker Spannung der zu vereinigenden Darmschlingen zu
gewagt ware. Die Methode ist also nicht nur ungefahrlicher,
sondern auch leistungsfahiger. Allerdings hat das Verfahren
auch seine Schattenseiten. Die Behan dlungsdauer ist eine viel
langere und der Operirte muss eine Zeit lang die Unannehmlich-
keiten eines widematfirlichen Afters fiber sich ergehen lassen.
Aber das sind, denke ich, Nachtheile, die durch den Vortheil der
grosseren Sicherheit und Leistungsfahigkeit reichlich aufgewogen
werden.
Ich stehe demnach nicht an, das geschilderte Verfahren der
zweizeitigen Darmresection als die Normalmethode bei alien
Fallen ron Tumoren des Dickdarms zu empfehlen, auch wenn
keinerlei Complicationen vorliegen. Beim Dfinndarm verwende
ich, falls nicht acuter Ileus vorliegt, die einzeitige Resection mit
primarer Darmnaht. Die Tumoren des Coccums sehe ich als
Grenzfalle an. Ich mache es vom Kraftezustand des Kranken,
von der Beschaffenheit des zuffihrenden Darmes, von den gros-
seren oder geringeren technischen Schwierigkeiten bei der Frei-
praparirung des Tumors abhangig, ob die primare Naht ange-
schlossen wird oder nicht. Bleibt nach Auslosung des Tumors,
was gewohnlich der Fall ist, eine breite, des Peritoneums ent-
behrende Wundflache zurfick, so dass ein grosserer toter Raum
entsteht, so gehe ich auch hier zweizeitig vor.
(P- 44) Gestatten Sie mir, meine Herren, noch in Kfirze auf die
Dauerresultate bei meinen Operirten einzugehen. In erster Linie
interessiren uns die Endresultate der Radicaloperation. Die
Operationsmethode, ob ein- oder zweizeitig, giebt hierbei keinen
Ausschlag. Ich darf daher die einzeitig und zweizeitig operirten
Falle zusammenfassen. Vorliegende Tabelle giebt Ihnen Auf-
schluss fiber die spateren Schicksale von 20 Operirten, fiber die
wir sichere iVachrichten hatten.
Radicaloperation
37 Falle, davon fix. Ueberlebend: 26 Falle. Keine Nach-
richt erhalten von 6 Fallen [2 davon mit Recidiv entlassen.]
Darmcarcinom
205
Es bleiben somit 20 Falle. Von diesen sind:
1. + an Recidiv: 9 Falle u. zw.
1 Fall nach 5! Jahr
1 Fall nach 14^ Monaten
1 Fall nach 13 Monaten
1 Fall nach 11 Monaten
1 Fall nach 8 Monaten
1 Fall nach 7 Monaten
1 Fall nach 6 Monaten
1 Fall nach 5! Monaten
1 Fall nach 3J Monaten
Summa 9 Falle, durchschnittliche Lebensdauer nach der Ope-
ration 15 Monate.
2. Es lebt mit Recidiv: 1 Fall nach 13 Monaten.
3. Es leben recidivfrei: 10 Falle u. zw.
1 Fall 9 j Jahre
1 Fall 5! Jahre
1 Fall 4! Jahre
1 Fall 4J Jahre
1 Fall 4 Jahre
1 Fall 2 Jahre
1 Fall ij Jahre
1 Fall ij Jahre
2 Falle \ Jahre
(p. 45) Die Operation liegt langer als 4 Jahre zuriick bei 12
Fallen, welche die Operation uberstanden. Von diesen sind 5 als
radical geheilt anzusehen.
Wie Sie sehen, ist das Endresultat, wenn wir eine Recidiv-
freiheit von 4 Jahren als Dauerheilung ansehen, ein sehr erfreu-
liches. Dass nach der Resection von Darmcarcinomen wirklich
Dauerheilungen vorkommen, die ein Jahrzehnt und daruber an-
halten, ist ja langst erwiesen. Ich brauche nur die bekannten
Falle von Gusserbauer-Martini, v. Bergmann, Rehn, v. Bramann,
Czerny, Kroenlein, Frank, Hochenegg, Lilienthal, Koerte anzu-
fuhren. Auch ein Fall aus meiner fruheren Beobachtungszeit
ist 16 Jahre recidivfrei geblieben. Solche Einzelbeobachtungen
geben uns allerdings noch keinen Aufschluss uber die Aussichten
auf Radicalheilung, auf die wir im einzelnen Falle rechnen konnen.
206
Medical Classics
Dies werden vielleicht spater ausgedehntere statistische Zusam-
menstellungen ermoglichen. Aber auch schon die jetzigen Er-
fahrungen berechtigen uns zu den schonsten Hoffnungen. In
dem Berichte von Koerte finde ich unter den 12 Fallen, bei
welchen die Operation auch mindestens 4 Jahre zuriickliegt, 4,
welche recidivfrei geblieben sind. Mit meinen Zahlen zusam-
mengenommen gabe das 24 Falle mit 9 Dauerheilungen =
37 , 5 pCt. _
Ueber die Enderfolge der Palliativoperationen bei Darmcarci-
nom geben folgende zwei Tabellen Aufschluss.
Colosto mie
Es haben gelebt:
A. Seit Beginn der Erkrankung.
1 Fall, 6§ Jahre
I Fall, 4I Jahre
3 Falle, 3! Jahre
1 FaU, 2| Jahre
I Fall, 2J Jahre
I Fall, 2J Jahre
1 Fall, a Jahre
Durchschnittl.: 3 J. 6 Mon.
B. Seit der Operation.
1 Fall, 4J Jahre
1 Fall, 3 i Jahre
1 Fall, af Jahre
2 Falle, 2 Jahre
x Fall, 1 J Jahre
1 Fall, 10 Monate
1 Fall, 5 Monate
1 Fall, 2§ Monate
1 Fall, ii Monate
Durchschnittl.: 1 J. 9 Mon.
Enteroanastomose
(p. 46) A. Seit Beginn der Erkrankung.
1 F a Uj 3! Jahre
Darmcarcinom
207
I Fall, 1 Jahre
1 Fall, ij Jahre
1 Fall, ij Jahre
1 Falle, 11 Monate
I Fall, 7 Monate
Durchschnittl.: 1 J. 6J Mon
B. Seit der Operation.
1 Fall, 95 Monate
1 Fall, 9 Monate
3 Falle, 7 Monate
1 Fall, 6| Monate
I Fall, 4J Monate
1 Fall, ij Monate
Durchschnittl.: 8J Mon
Auffallend ist die lange Lebensdauer einzelner Falle nach der
Colostomie. Wir haben bei diesen Kranken versucht ausser der
Lebensdauer nach der Operation noch die Lebensdauer seit
Beginn der ersten Krankheitserscheinungen festzustellen, um uns
daraus ein Bild in Bezug auf die Lebensdauer der Darmcarci-
nomkranken iiberhaupt zu machen. 1 Wie Sie sehen, finden wir
auch hierbei auffallend hohe Zahlen, welche mit der bisherigen
Annahme in Bezug auf die Lebensdauer beim Darmcarcinom
nicht ubereinstimmen. Dieselbe wurde bisher allgemein ent-
schieden zu niedrig veranschlagt. Zur Vervollstandigung haben
wir uns auch iiber das weitere Schicksal der nicht operirten oder
nur einer Probeincision unterworfenen Kranken zu unterrichten
gesucht. Die Zahlen sind hier, wie Sie aus beifolgender Tabelle
ersehen, viel ungiinstiger.
Nicht operirte Falle und Frobencisionen
Es haben gelebt seit Auftreten der ersten Erscheinungen :
1 Fall, 20 Monate
1 Fall, 18 Monate
I Fall, 17 Monate
1 Die Gesammtzahl der unter A, angefuhrten Falle ist sowohl bei der Colostomie als
auch bei der Enterostomic kleiner als unter B., wcil nicht in alien Fallen der Beginn der
Erkrankung genugend festzustellen war.
2o8
Medical Classics
1 Fall, 12 Monate
2 Falle, 9 Monate
i Fall, 8 Monate
i Fall, 3 Monate
Durchschnittlich: 12 Monate
Offenbar waren es von Haus aus malignere, rascher wachsende
Carcinome, die sich eben deshalb zu einer Operation nicbt
eigneten.
(p. 47) In Bezug auf die Erfolge der Operation bei Ileus infolge
von Darmcarcinom kann ich mich ganz kurz fassen, da die ein-
schlagigen Beobachtungen in einer spateren Mittheilung aus
xneiner Klinik uber Ileus noch eingehender besprochen werden
sollen. Von 23 Fallen, die mit acutem Ileus in die Klinik kamen
und operirt wurden, genasen 12 vom Ileus; 11 starben. Auffal-
lend ist der Unterschied in der Prognose je nach dem Sitze des
obturirenden Carcinoms; je hoher es liegt, desto ungunstiger die
Prognose. 14 mal sass der Tumor in der Flexura sigmoidea, nur
3 von den Operirten starben, wahrend von den 9 Kranken mit
hoherem Sitze des Carcinoms 8 zu Grande gingen. Ferner zeigt
sich an unserem wenn auch kleinen Material, dass die Prognose
um so besser ist, je geringfugiger der vorgenommene EingrifF.
Von 15 Fallen, in welchen nur ein Anus praeternaturalis angelegt
wurde, starben nur 4. 10 mal sass das Carcinom in der Flexura
sigmoidea, von den Fallen starb nach der Colostomie nur I.
Von 5 Patienten mit hoherem Sitze des Tumors starben 3. Die
2 Falle, in welchen die Enteroanastomose vorgenommen wurde,
starben beide, ebenso 5 Falle, in welchen die Resection ausge-
fuhrt wurde.
Nach diesen Erfahrangen ist es begreiflich, dass ich es mir
zum Grandsatze gemacht habe, bei Ileus wegen Darmcarcinom
in der Regel mich auf die einfache Colostomie zu beschranken.
Ich wurde nun ausnahmsweise, wenn die Verhaltnisse besonders
gunstig liegen, die zweizeitige Resection vornehmen. Die ein-
ache Colostomie hat neben anderen noch den enormen Vortheil,
dass wir sie unter localer Anaesthesie vornehmen konnen. Der
EingrifF wird dadurch fast ganz ungefahrlich. Die Vornahme
der Colostomie unter localer Anaesthesie setzt allerdings voraus.
Darmcarcinom 209
dass wir den Sitz des Hindernisses mit annahernder Sicherheit
vorausbestimmen konnen. Dies ist mit unseren heutigen diag-
nostischen Hilfsmitteln in der grossen Mehrzahl der Falle moglich.
Ist trotzdem ein Irrthum untergelaufen und hat man z. B. einen
Schnitt zum Anus sigmoideus angelegt, ohne daselbst die geblahte
Darmschlinge zu finden, so wird man durch eine zweite Incision
unter localer Anaesthesie in der Ileocoecalgegend dem Kranken
gewiss viel weniger schaden, als wenn man in Narkose die Bauch-
hohle breit eroffnet und erst nach dem Hindernis sucht.
Surgical Experiences with
Intestinal Carcinoma'
BY
J. VON MIKULICZ
in Breslau
tinent cases. In the same year DeBovis, in the Review of Surgery,
gave a critical compilation of approximately 450 cases of intestinal
carcinoma which had been treated surgically, together with a well
prepared review of the experiences recorded in the literature. It
will therefore appear almost superfluous to bring the subject up
again for discussion. And yet every surgeon must be convinced of
the fact, by his own experiences as well as by a perusal of the
literature, that we are still at some distance from a solution of
the whole problem. Even if today we can say that intestinal
carcinoma offers one of the most satisfactory fields of abdominal
surgery, our results leave much to be desired. They must be
improved by a perfection of the technique; they must also be
improved by an exhaustive study of the clinical phenomena of
intestinal carcinoma; for by this means we will be enabled to
1 Discourse presented at the 31st Congress of the German Society of Surgery. Pub-
lished in Arch. f. khn. Chir., 69: cS-47, J 9 ~ 3 '
Intestinal Carcinoma
2 1 1
recognize the malady earlier and to undertake surgical treatment
in an earlier stage. Perhaps my modest experiences will offer
a small contribution thereto.
During the course of the last eleven years, 106 cases of malig-
nant intestinal tumors — with the exception of those of the
rectum — have come under observation in the Breslau clinic.
Five of these were sarcoma, three of the small intestine, and
two of the large. One presented an endothelioma of the trans-
verse colon. One hundred times it was a question of carcinoma;
of these five occurred in the small intestine and 95 in the large
bowel.
Since intestinal sarcoma in most cases presents the same clinical
picture as intestinal carcinoma, in the following discussion I
take the liberty of considering the two tumor forms as one for
all practical purposes. 1
According to sex, 80 cases were in men and 26 in women.
Such a marked preponderance in the male sex (3:1) to my knowl-
edge has not been presented in the other statistics. According
to DeBovis the ratio of male to female is 54:46.
In reference to age, all periods from the second to the eighth
decade of life are represented in my series. The youngest patient
was 16 years of age. The following table shows the distribution
of cases according to age.
Age
Males
Females
Total
Under 20
—
I
I
20-29
3
I
4
3°~39
10
5
*5
40-49
*9
3
22
5°~59
23
10
33
60-69
21
6
27
70-79
3
—
3
Over So
1
—
1
1 The striking differences in the clinical courses of intestinal sarcoma and intestinal
carcinoma which occasionally occur, namely the rapid growth and the complete lack of
the phenomena of stenosis in sarcoma, are to be made use of in the differential diagnosis
of the single case only with extreme caution, since we also observe the greatest difference
in both directions in the various forms of intestinal cancer. A detailed discussion is to be
found in the chapters of the third volume of the Handbook of Practical Surgery by v.
Bergmann, v. Bruns and v. Mikulicz.
212
Medical Classics
According to the level of intestinal segment affected, the
tumors were distributed in the following manner:
a) Small intestine 8 cases (5 carcinoma, 3 sarcoma).
b) Cecum 20 cases (19 carcinoma, 1 sarcoma).
c) Colon (with exception of cecum and sigmoid flexure) 40
cases as follows:
a) Ascending colon : 6 cases.
b) Hepatic flexure: 7 cases.
c) Transverse colon : 8 cases.
(7 carcinoma, I endothelioma)
d) Splenic flexure: 12 cases.
e) Descending colon: 4 cases.
f) Colon without exact localization : 3 cases.
d) Sigmoid flexure: 3 1 cases.
e) Point of origin unknown 1 7 cases (1 sarcoma, 6 carcinoma).
The figures given coincide well with the other statistics, which
are for the most part more extensive, in that they show that the
most common site of predilection for intestinal carcinoma is
the sigmoid flexure and the next most common is the cecum.
Although thedistribution of intestinal carcinoma in the various
portions of bowel is so regular, the clinical course in individual
cases is without any standard rule at all, if we disregard the
fact that the height of the affected section of gut exerts a certain
influence on the development of the clinical phenomena. It
is well known that a tumor which has once produced outspoken
functional disturbances in the intestine, runs a different course
according to whether it is in the small bowel, cecum or in the
lower portion of the large bowel. In general it may be said
that the higher the intestinal cancer, the more pregnant the
phenomena and the more stormy the disturbances. But dis-
regarding the location, an intestinal cancer at one and the same
spot can in one case remain completely latent for a long period,
at another time produce vague intestinal symptoms, a third
time the symptoms of chronic stenosis and a fourth time acute
1 Thc cases of indefinite localization refer to patients not operated on, in whom the
diagnosis could be made by the clinical findings, and a few times, as in one case of in-
testinal sarcoma, on the basis of extirpated lymph nodes.
Intestinal Carcinoma 213
ileus. We need not wonder over the variability of the course
if we but consider that an intestinal tumor produces no symptoms
of itself alone, since it is established in an organ which, as we
know, has no sensory nerves. The effect on peristalsis as a
result of the infiltration of a limited segment of intestinal wall
is also of no significance, for the passage of the products of diges-
tion, as the adjacent portion of gut above is powerful enough to
act vicariously for the section of intestine not capable of peri-
stalsis. Only through complications does cancer of the intestine
become clinically noticeable. These are stenosis, ulceration and
hemorrhage. The last two complications are as a rule made
manifest only in carcinomas situated low down, in the region of
the flexures and the descending colon, by the admixture of
blood and pus with the stools; bleeding in higher locations, if
profuse, is a rare occurrence in intestinal cancer, as is well known.
We must regard stenosis as the most constant complication which
sooner or later enters into almost every case, but we unfortunately
know it is not an early symptom. Probably most carcinomas
produce stenosis in the anatomical sense very quickly, but for a
long time this need not lead to stenosis in the clinical sense, that
is, the prevention of passage of contents at the affected area.
The section of gut lying above the stenosis compensates for a
long time as the result of a constantly increasing hypertrophy,
and, indeed, this may be so complete that no functional disturb-
ances need become evident. To what extent this hypertrophy
can go is best shown in those cases where a former apparently
healthy person is suddenly stricken with acute ileus, as the
cause of which there is found an intestinal cancer already pos-
sessing a marked degree of stenosis. Clinically, stenosis occurs
when severe symptoms of intestinal catarrh develop as the result
of continued congestion above the carcinoma, when insufficient
passage through the stenosed area of the bowel leads to forceful,
cramp-like peristalsis (rigid bowel), or when by a chance occur-
rence (foreign body, inflammatory swelling) the narrowed spot
suddenly becomes wholly impassable. At this point I need not
go further into the well known symptoms of chronic intestinal
stenosis or acute occlusion of the gut. I should like to stress
Medical Classics
214.
the fact, though, that intestinal carcinoma commonly can remain
symptomless over a long period of time or run an atypical course,
so that one should also include carcinoma in the differential
diagnosis of apparently insignificant disturbances of intestinal
function, especially when the phenomena occur in an elderly per-
son who has previously enjoyed faultless digestion. Occasionally,
by means of a thorough examination of the abdomen, inflation
of the bowel and other methods of investigation, a palpable tumor
or other indications of intestinal tumor are found long before
severe functional disturbances occur.
Moreover I assume it is known that the histologic structure
of the carcinoma exerts a definite effect as to whether a marked
degree of stenosis develops early or late. In this respect the
contrasts are striking between the clinical manifestations of
large extensive tumors and small tumors not at all palpable
through the abdominal wall. A large, relatively soft, extensive,
ulcerating tumor which maintains the intestinal lumen can run
its course without much hindrance to the intestinal passage,
while a small scirrhous cancer, limited to a few centimeters,
can cause severe symptoms of stenosis very early because of
the firm contraction. Carcinoma of the latter type are common
in the region of the sigmoid flexure.
Perhaps it would not be unsuitable to classify intestinal car-
cinomas in various types according to their clinical course or the
stages passed through in the single case, as, for example, DeBovis
does in differentiating three types:
I. Type of absolute or relative latency.
1 . Gastrointestinal type.
3. Type of severe occlusion.
This preliminary arrangement certainly has qualifications,
since most cases pass through at least two and perhaps all three
stages, one after the other.
From another and more practical point of view, I should like
to differentiate the following three periods in the course of in-
testinal carcinoma.
A) Latent period.
B) Period of initial symptoms.
Intestinal Carcinoma
215
C) Period of clinically demonstrable symptoms.
A) In regard to the latent period, it is self-evident that we
can only state suppositions. Observations made later when a
palpable abdominal tumor presents in a striking way as the
first symptom of an intestinal cancer or cases in which an acute
ileus suddenly occurs as the result of an intestinal tumor, without
any prodromal symptoms, indicate that intestinal carcinoma can
exist latently for a long period, at any rate much longer than is
commonly assumed. Also the observation that a patient with
intestinal cancer may live for some years in relatively good health
following colostomy (in a case under my observation four and
one-half years), speaks in a like manner. These observations
also show that intestinal carcinoma, contrary to the view of
most clinicians, is a relatively benign carcinoma, because glan-
dular metastases and metastases to other organs in many cases
do not occur until late. We must call special attention to this
because it speaks highly for the appropriateness of operative
therapy in intestinal cancer, a fact which at present is all too
little recognized by clinicians of internal medicine. If I am
obliged to give approximate figures, I should say that the latent
period in intestinal cancer amounts to one-half to three years.
B) As far as the initial symptoms are concerned, as already
stressed in the preceding remarks, they may take extremely
variable forms. By these I understand those symptoms which
for the first time call the patient’s attention to his affliction,
regardless of whether or not he seeks medical attention at once.
According to my observations I am able to differentiate two
groups.
a) Cases without characteristic disturbances of the intestinal
canal; to these belong 58 of the 106 cases observed by me, thus
more than half, and are given as follows:
1. Forty-three cases of vague gastrointestinal phenomena, for
the most part irregularities of bowel movements, in which either
obstipation or an inclination to diarrhea existed or both con-
ditions alternated.
In 9 cases a tumor of the abdomen was noticed accidentally,
without any disturbances whatever on the part of the intestine;
2 1 6 Medical Classics
in addition, in 12. cases a tumor was noticed along with the
previously mentioned vague gastrointestinal disturbances.
3. In 6 cases there were local peritonitic phenomena v/hich
were obviously caused by the ulcerating tumor proceeding to
perforation; 5 of these cases concerned a tumor of the cecum
which later presented the picture of perityphilitis with abscess
formation; in one case perforation of the bladder occurred without
any preceding symptoms, cystitis with pneumaturia being the
alarming symptom.
b) Cases in which the symptoms manifested themselves as
definite disturbances of the intestinal canal, 48. Of these, 39
cases had signs of chronic intestinal stenosis, 5 with acute ileus
without prodomal symptoms; 4 cases could be regarded as chronic
ileus, that is, as borderline cases between chronic intestinal
stenosis and acute ileus.
C) To regard the period of clinically demonstrable symptoms
as a special state of the disease is obviously entirely arbitrary,
for the beginning of this stage depends on when the patient
seeks medical aid. Many times, as for example in all cases of
ileus, this stage coincides with the initial stage. But after all
we are permitted to decide on some sort of a classification of
this kind, as far as we are definitely able to make the diagnosis
at a time when the patient knows himself to be so seriously ill
that he seeks aid in earnest, namely from a surgeon. Of the
106 cases seeking our aid, 84 (80 per cent) already showed out-
spoken functional disturbances on the part of the intestine, and
indeed in 45 cases signs of a pronounced chronic ileus were present,
28 had acute ileus (with these are included 2 cases who had
colostomies performed outside of the clinic because of ileus),
and 11 cases had a chronic ileus.
In only 22 cases (20 per cent) were typical disturbances of
intestinal function lacking. In these cases the intestinal tumor
caused the following phenomena:
1. In 7 cases the symptoms were limited to a palpable tumor
in the abdomen.
2. Eight times signs of perforation were present; one each of
perforation into the general abdominal cavity with peritonitis.
Intestinal Carcinoma
2 I 7
perforation into the bladder and perforation into the stomach;
in 5 cases a perityphilitic abscess was present.
3. In 7 cases at the time of clinical observation only vague
gastrointestinal symptoms presented.
Thus we see that, at the time of clinical observation, with
the exception of 7 cases, severe symptoms always presented,
pointing to the diagnosis of intestinal tumor or at least a stenosing
or ulcerating intestinal process. So in these cases the diagnosis
was determined with sufficient certainty to answer the question
for the surgeon as to whether or not operative intervention was
in order. It would take me too long to go further into the
difficulties of the differential diagnosis between intestinal carci-
noma and other stenosing and ulcerating processes of the intes-
tine. Frequently enough, the surgeon must be satisfied with
the general diagnosis of “Intestinal Tumor” or “Intestinal
Stenosis”, and if no contraindications are present, the possibility
of an intestinal carcinoma justified an exploratory laparotomy,
by means of which the further diagnosis and the nature of the
operation to be undertaken must then be decided. Thus far a
precise differential diagnosis of the primary disease is of but
slight practical significance. On the other hand, in one respect
in our treatment, we must sharply separate the clinical manifes-
tations of intestinal carcinoma from other more insidious symp-
toms according to whether the case presents the picture of acute
ileus or chronic intestinal stenosis. Many experienced surgeons,
even Koerte, have referred to this point; but nevertheless it
should not be held as a binding rule to regard a case of intestinal
carcinoma with acute ileus and one without ileus as two diseases,
which not only are to be regarded with different prognoses but
also to be handled differently in regard to operative therapy.
The patient showing chronic symptoms of intestinal carcinoma,
if he is well nourished and if no extensive metastases, ascites
or advanced cachexia are present, has as a rule sufficient resistance
to stand severe action, in particular, radical operation. We
can avoid the chief danger, that of peritoneal infection, almost
with assurity by the two stage method of resection to be de-
scribed later. On the other hand a carcinomatous patient with
2 1 8 Medical Classics
acute ileus is in all ways a much poorer risk. At the most he is
no longer equal to a major intraabdominal operation, even if
technically favorable for intestinal resection. At this point it
would take too long to present all the reasons for this. Statis-
tics show that patients with acute ileus, for the most part, suc-
cumb to procedures which patients of the first category withstand
easily. Only exceptionally is such a patient successfully brought
through a resection. The three cases on which I operated all
expired. (One, it is true, had successfully weathered the main
operation, the first act of the two stage resection and died only
at a further operation.) Enteroanastomosis alone would be too
severe a procedure in most cases. Therefore we should limit
ourselves to the necessary minimum of action in ileus due to in-
testinal carcinoma; that is, first of all perform only the colostomy,
and if the tumor is suitable for resection, carry this out only
at a second session, after the over-congested bowel whose nourish-
ment has been severely damaged, as well as the patient, have
completely recovered themselves.
xAfiter what has been said no further explanation is needed if,
out of my 106 cases, I separate the 2.3 which were brought to the
clinic with acute ileus from the remaining 83. Among the latter
are also found those which were previously stricken with acute
ileus elsewhere than the clinic and in which, after successful
colostomy, we performed a second operation.
We will now consider the latter cases, those with chronic
symptoms who came under our care. As you know, along with
resection, simple colostomy and intestinal anastomosis, with
complete or incomplete exclusion of intestine are at our disposal
as palliative measures. We are not always in a position to decide
previously as to whether the radical operation will be possible
or whether we will be limited to one of the palliative operations.
In these cases the operation will have to begin as an exploratory
incision. In general we are agreed on the principles which
should lead us to the choice between radical operation and one
of the palliative procedures as soon as the abdominal cavity
is opened. Still, in individual cases, it will depend a great deal
on personal experience as to whether the operator decides on the
Intestinal Carcinoma
219
extensive radical operation or on a palliative operation or indeed
if he close the abdominal cavity without having effected his
object. Previously, when I used the single stage resection as a
rule, I decided on resection only under favorable general and
local conditions. Since I have used the incomparable less danger-
ous two stage method I go much further. Naturally, although
we review the indications sufficiently, a not inconsiderable num-
ber of cases will remain in which we desist from any operation.
The 83 cases of malignant tumor with chronic symptoms are
arranged according to treatment used as follows:
Not operated on
.. 17 1
Exploratory incision
• 7
0
Colostomy'
.. 6
0
Intestinal anastomosis with exclusion of bowel. . . .
. . 16
3
Resection
• 37
11
2 9 - 7 %
Of these, single stage with primary suture
21
9
4 2 - 9 %
Two stage with protrusion
.. 16
n
12 - 5 %
There is nothing special to be noted in regard to the direct
results of simple exploratory incision and the palliative opera-
tions. On the other hand, to go further into the results of
the radical operation will be well worth while. Without further
ado the great superiority of the two stage method of resection
over the single stage with primary suture strikes the eye. In
the latter a mortality of 42.9 per cent, in the former only 12.5
per cent. The result appears even more favorable when we
consider that the two deaths with the two stage method can not
be charged to the operation itself. One case died seven weeks
after operation from marasmus, a result of carcinoma metastases;
in the second case peritonitis was the cause of death and indeed
resulted from rupture of the carcinomatous infiltrated descending
colon, which was adherent to the transverse colon and tore on
being loosened.
As far as I am acquainted with the literature the single stage
resection of the carcinomatous gut with primary suture is still
x Of these, one case died in the clinic. Operations as a rule were avoided because of
too extreme cachexia, metastases, etc. Several times the patient refused the proposed
operation.
220
Medical Classics
today almost generally in vogue. Up to now the results of this
operation are far from satisfactory, even for carcinoma in the
region of the large howel alone, regardless of whether the union
of gut is brought about by the old method of circular intestinal
suture or through lateral implantation or apposition or finally
with the intestinal button. I need only quote a few statistical
counts. Of Koerte’s 19 cases of radical operation, 7 died (of
these to be sure 3 were operated on with ileus), of Czerny’s 18
cases 9 died, of von Bramann’s 14 cases 6 died, of Kroenlein’s
11 cases 6 died. The extensive statistics of DeBovis, who has
collected 104 cases from associated series of well known surgeons,
coincide fairly well with these figures. The mortality amounts
to 38.4 per cent. In addition DeBovis has collected 51 fatal
cases following single stage resection from other individual publi-
cations. Thirteen times collapse, 30 times peritonitis was the
cause of death. Also interesting is the fact that in cases treated
without drainage of the peritoneal cavity, the mortality was
one-third higher than that of the drained cases. The cases of
death from collapse indicate that the operation was too severe
for a considerable portion of the patients. The 30 cases of
peritonitis indicate that, in more than half of the fatal cases,
either the peritoneum was infected during the operation or
peritonitis subsequently developed because of defect of the su-
tures. Without a doubt the danger of peritoneal infection,
whether primary or secondary to defect of the sutures, is enor-
mously great. That is easily understood if we consider the
conditions under which the intestinal suture is undertaken.
Intestinal union in the large bowel (of this only do we speak
here) is in itself not very reliable, whatever method we may
employ. The lessened strength of the wall of the large gut,
the poorer blood supply, the sluggish peristalsis as a result of
which the firm feces stagnate at the site of suture, give far less
assurance of primary union than in the small intestine; added
to these is the fact that in intestinal carcinoma as a rule they
are not normal segments of intestine which we join to one another.
The segment above is commonly overdistended and as result
is poorly nourished; also it is often paretic which further increases
Intestinal Carcinoma
221
the stagnation ’and the insecurity of the sutures. The danger
of primary infection of the peritoneum from the opened intestine
is regarded as much greater than is commonly accepted. Even
if we carefully separate the portion of gut to be resected from
the remainder of the peritoneal cavity by temporary tamponade,
the spread of intestinal bacteria in the serosa itself throughout
a wide range is not prohibited. Hans Buchbinder , 1 in an inter-
esting work, has demonstrated that the bacteria from the finest
puncture of the gut spread over the surface of the serosa with
great rapidity, and indeed not only on that portion directly
concerned but also on the neighboring loops of bowel. Accord-
ingly we must consider that in every gastric and intestinal opera-
tion a certain number of bacteria gain admission to the peritoneal
cavity in spite of all precautions. The longer the operation
lasts, the greater the number of bacteria will be. Now doubtless
in many cases, we can almost say as a rule, a slight amount of
bacterial invasion is overcome by the peritoneum; the effect
produced is the circumscribed peritonitis observed in all stomach
and intestinal operations, leading to partially protective ad-
hesions in the region of the suture. The capacity to overcome
successfully an insignificant peritoneal infection of such a nature,
depends in the first place on the resistance of the entire organism.
The patient with acute ileus is, as a result of the intestinal intox-
ication, so lacking in resistance that he can not overcome a
minimum of infection. Also in chronic intestinal stenosis which
we know accompanies intestinal cancer as a rule, the patient is
found in a state of chronic intoxication, by which he is doubtless
less resistant to intestinal bacilli. In this we find sufficient
explanation for the poor results of the single stage resection of
the intestine for cancer. I do not doubt that the frequent pneu-
monias following this operation in part at least are to be at-
tributed to a bacterial infection of the peritoneum which locally
is overcome but which leads to pneumonia by way of small
pulmonary emboli.
1 Experimental Investigations on Living Animal and Human Intestine, Deutsche
Zdtschrift fur Chirurgie, voL 55, p. 45S.
222 Medical Classics
There is no doubt therefore that we can produce an improve-
ment in the results only if we:
i. Make the operation less severe and so lessen the danger
of collapse, and
i. Prevent peritoneal infection during the operation and during
the course of healing. By means of the two stage operation
we accomplish both.
The idea of removing intestinal carcinoma by a two stage
operation is in no way new. Even at the end of the year ’70,
Schede, Gussenbauer, Maydl, v. Volkmann and others found
themselves forced, partly because of the technical impossibility
of uniting the intestinal extremities by suture after resection of
the tumor, and partly because loss of strength of the patient
demanded a rapid termination of the operation, — as I say, they
were forced to close the abdomen with the formation of an arti-
ficial anus. The latter could be closed if conditions justified it.
Along with this two stage operation resulting from necessity,
other combinations were later used, namely, formation of an
artificial anus above the stenosed area at a time when ileus ex-
isted, and resection with typical intestinal suture at a later time.
A further commonly known combination is that of primary
intestinal anastomosis with partial or complete exclusion of the
diseased portion of gut and extirpation of the tumor at a later
sitting. The two last named combinations have the great ad-
vantage that they, first of all, empty the proximal bowel and
thus do away with the secondary changes. The second operation
is then carried out on approximately normal intestinal parts.
However, these two combinations do not avoid one of the chief
sources of danger, namely, the primary and secondary infection
of the peritoneum. This danger, along with all others, is best
avoided by the two stage operation, which for more than five
years now I have performed on practically all tumors of the large
bowel. Essentially the operation consists of freeing the tumor
of all connections, as in the single stage resection, up to the
communication with the afferent and efferent segment of gut.
The tumor, thus mobilized, is brought out through the abdominal
wound and the latter closed off up to the point of exit of the two
Intestinal Carcinoma
223
sections of bowel; the tumor is resected extraperitoneally either
at once or after the course of twelve to forty-eight hours. The
resulting artificial anus is later closed.
The principle of this procedure was, to my knowledge, first
employed by Oscar Block in Copenhagen in the year 1892. In
a case of ileus he found the cause to be a freely movable tumor
situated in the sigmoid flexure. He brought this out on the
abdominal wall together with the long meso-sigmoid and incised
the gut above the tumor. After the subsidence of symptoms
of ileus he carried out an extraperitoneal resection, followed in
four months by closure of the artificial anus with circular in-
testinal suture. Block at first recommended this procedure only
for intestinal tumors with movable mesentery and at that time
expressed the conviction that the greatest dangers of the opera-
tion were avoided by the extra-abdominal resection of the bowel.
Two years later he advanced a step further, in that he mobi-
lized a less movable tumor of the descending colon sufficiently
by incising the fold of the root of mesentery and peritoneum.
Whether Block later went still further and resected the mesen-
tery primarily in the manner which I employ, I do not know.
At any rate, the idea is not much different. It is clear that the
original procedure of Block, disregarding its limited applicability,
has the great disadvantage that the regional lymph glands remain
unnoticed because the mesentery is left undisturbed. Other
surgeons besides Block have carried out a similar procedure in
similar cases; for instance, Allingham, W. Edmunds, Hochenegg,
and others. In all I find that DeBovis describes eight operations
of this type, all ending with favorable results. I have already
mentioned that of my sixteen cases only two terminated fatally
and that in both instances this method of operation had no bear-
ing on the fatal outcome. The operation, as it has been worked
out in- my clinic during the course of recent years, shapes itself
in detail in the following way.
The intestinal tumor along with the diseased lymph glands
and the corresponding portion of mesentery are freed from all
attachments as in the single stage resection, so that the tumor
is finally connected only with the gut leading to and from it.
224 Medical Classics
The mesentery must be loosened sufficiently to allow the section
of bowel which is to be resected to be laid out on the surface of
the abdomen without tension. When this is done the abdominal
wall is closed off so that only the cleft necessary for the passage
of the afferent and efferent segments of gut is left open; this
cleft must not be so narrow that the afferent section is com-
pressed. A series of serosal sutures is placed at the point where
parietal peritoneum comes in contact with the protruding por-
tions of bowel, these sutures also closing off the peritoneal cavity
at this point. The outer skin is sutured carefully to the pro-
truding bowel (without tamponades). Next the line of suture
as well as the surface of contact between exposed gut and skin
wound are thickly spread with zinc paste and over this a sterile
dressing is placed. Over the bandage comes a large piece of
water-proof material with a slit just large enough to allow the
protruding gut to be drawn through. Thus the tumor which
is to be resected is finally separated from the abdominal cavity
not only by the sutured abdominal wall but also by the protective
dressing. Formerly I removed the tumor only after the passing
of twelve to forty-eight hours, but now I usually do it at once.
A thick glass tube is fastened into the discharging segment of
gut and a thick rubber tube fastened to the glass one, so that the
intestinal contents flow off.
The wound in the abdominal wall in this procedure heals, as
far as it is sutured^ by primary intention. After two to three
weeks, by means of my spur-crusher, I transform the artificial
anus resulting from the removal of the tumor first into a fecal
fistula and later make a closure by suture.
The advantages of this procedure are evident. The main
operation is shorter than by the single stage method, the peri-
toneal infection during the operation is absolutely avoided, and
one can thus attempt it much earlier on a patient debilitated by
the disease. A further advantage is that the operation can be
performed in cases of wide extension of the tumor or in deep
locations, as for example in the lower part of the sigmoid flexure,
where it would be too dangerous to unite the intestine because
of too forceful tension on the loops of gut. The method is not
Intestinal Carcinoma
225
only less dangerous but also more easily performed. Of course
the procedure also has its drawbacks. The duration of treatment
is longer and the patient operated on must bear with the un-
pleasantness of an artificial anus for a long time. But I think
these disadvantages are greatly outweighed by the advantages
of greater safety and increased ease of performance.
Accordingly I do not hesitate to recommend the previously
described procedure of two stage resection of intestine as the
logical method in all cases of tumors of the large bowel, even if
no complications are present. In the small intestine, if acute
ileus is not present, I use the single stage resection with primary
suture. Tumors of the cecum I regard as borderline cases. I
depend on the strength of the patient, on the condition of the
proximal bowel and on the more or less technical difficulty in
freeing the tumor, as to whether or not primary suture will be
the suitable closure. If after freeing of the tumor, a broad
traumatized surface devoid of peritoneum remains, as is usually
the case, so that a larger dead space remains, I perform the two
stage operation.
Allow me, Gentlemen, briefly to go into the existing results
of my operation. First of all we will consider the end results
of radical operation. In this, the method of operation, whether
single or two stage, makes no great difference. Therefore I have
taken the liberty of grouping together cases operated on by the
single stage and two stage. The table presented gives you an
explanation of the subsequent fate of ao patients operated on, of
whom we have definite information.
Radical Operation
37 cases, of these 11 died. Surviving: 16 cases. No informa-
tion obtained of 6. (Two of these discharged with recurrences.)
In all, ao cases remain. Of these:
1. Died with recurrences, 9 cases as follows:
1 case after 5J years
1 case after 14^ months
1 case after 13 months
1 case after 11 months
Medical Classics
226
1 case after 8 months
1 case after 7 months
1 case after 6 months
1 case after 5^ months
1 case after 3§ months
Summary: 9 cases, average length of life post-operative 15
months.
1 . Living with recurrence, 1 case after 13 months.
3. Living and free from recurrence, 10 cases as follows:
1 case, 9! years
1 case, 5! years
I case, \\ years
x case, 4! years
x case, 4 years
1 case, a years
1 case, i§ years
1 case, 1 1 years
2 cases, j year
Operation was performed more than 4 years ago on 12 cases
which survived the operation itself. Of these 5 are to be regarded
as radically cured.
As you see, the end result, if we regard a period of four years
free from recurrence as permanent cure, is very encouraging.
Indeed, it has long been proven that permanent cure lasting for
a decade and longer really can occur following resection for
intestinal cancer. I need only mention the well known cases of
Gussebauer-Martinie, v. Bergmann, Rehn, v. Bramann, Czerny,
Kroenlein, Frank, Hochenegg, Lilienthal, and Koerte. Also one
case from my early period of observation has remained free from
recurrences for sixteen years. But such a single observation
gives us no information as to the expectations of radical cure on
which we can reckon in individual cases. Perhaps this will be
made possible later by more extensive statistical compilations.
However, the present experience affords us the most favorable
hopes. In Koerte’s report I find among the 12 cases in which
operation is at least four years ago, 4 which have remained free
from recurrence. Taken with my figures this gives 24 cases
with 9 permanent cures or 37.5 per cent.
Intestinal Carcinoma
The two following tables give information on
of palliative operations in intestinal cancer.
Colostomy
There have lived:
A. Since the onset of the disease :
i case, 6f years
i case, 4J years
3 cases, 3! years
I case, 2§ years
1 case, 2f years
1 case, i\ years
1 case, 2 years
Average : 3 years, 6 mon ths.
B. Since the operation:
1 case, 45 years
1 case, 3J years
1 case, 2f years
2 cases, 2 years
1 case, if years
1 case, 10 months
1 case, 5 months
1 case, 2f years
1 case, if years
Average: 1 year, 9 months.
Intestinal Anastomosis
A. Since the onset of disease:
1 case, 3f years
1 case, 2 years
1 case, if years
1 case, if years
2 cases, 11 months
1 case, 7 months
Average: 1 year, 6f months.
B. Since the operation:
1 case, 9-f months
227
the end results
228
Medical Classics
i case, 9 months
3 cases, 7 months
1 case, 6| months
1 case, 4i months
1 case, i§ months
Average: 8J months.
The duration of life of individual cases after colostomy is
strikingly long. In these patients we have attempted to deter-
mine the length of life from the beginning of the first symptoms
of disease and the length after operation, in order to form a
picture relating to the duration of patients with intestinal car-
cinoma as a class. 1 As you see, we find here strikingly higher
figures which do not coincide with the view hitherto existing
in regard to the duration of life in intestinal carcinoma. This
estimation in general has been too low. For the sake of com-
pleteness we have sought to acquaint ourselves with the fate of
patients not operated on or subjected to an exploratory incision
only. The results here, as will be apparent to you from the
following table, are much more unfavorable.
Non-operative Cases and Exploratory Incision
There have lived since the appearance of the first symptoms:
1 case, 20 months
1 case, 18 months
1 case, 17 months
1 case, 12 months
2 cases, 9 months
1 case, 8 months
1 case, 3 months
Average: 12 months.
Obviously these were from the beginning more malignant,
more quickly growing carcinomas, which, therefore, did not lend
themselves to operation.
In regard to the results of operation in ileus resulting from
1 The total count of cases listed under A is smaller for colostomy as well as enterostomy
than under B because in all cases the beginning of the disease could not be definitely
determined.
Intestinal Carcinoma
229
intestinal cancer I can limit myself, since the pertinent observa-
tions will be more exhaustively described in a later communica-
tion from my clinic on ileus. Of 23 cases which entered the
clinic with acute ileus and were operated on, 12 recovered from
the ileus; 11 died. The difference in the prognosis according
to the location of the obstructing carcinoma is striking, the
higher it lies, the more unfavorable the prognosis. Fourteen
times the tumor was situated in the sigmoid flexure, and only
3 of those operated on died; while of the 9 patients with high
location of the cancer, 8 died. Furthermore, our material, even
though limited in amount, shows that the less severe the pro-
cedures instituted, the better the prognosis. Of 15 cases in
which only an artificial anus was made, only 4 died. On 10
occasions the carcinoma was situated in the sigmoid flexure,
and only 1 died following colostomy. The two cases in which
enteroanastomosis was done died, as did 5 cases in which resection
was performed.
After these practical experiences, it is understandable that I
have made it a principle to limit myself to simple colostomy as
a rule in cases of ileus due to intestinal cancer. I would undertake
the two stage resection only in exceptional cases where conditions
are especially favorable. The simple colostomy has, along with
others, the enormous advantage that it can be performed under
local anesthesia. The procedure is thus almost completely with-
out danger. The performance of colostomy under local anes-
thesia presupposes that we can localize the site of the obstruction
with approximate certainty. With our present day diagnostic
aids this is possible in the great majority of cases. If, in spite
of these, a mistake is made and if an incision for an “anus sig-
moideus” is made without finding the distended loop of bowel,
one will do less harm by making a second incision in the ileocecal
region under local anesthesia, than by opening the abdominal
cavity widely under narcosis and thus seeking for the obstruction.
(the end)
MEDICAL CLASSICS
vol. 2 November, 1937 no. 3
CONTENTS
Portrait of Thomas Addison ------ 232
Thomas Addison
Biography 233
Eponyms - -- -- -- -- -- 234
Bibliography of Writings 234
Bibliography of Biographies ----- 236
Index to Bibliography ------- 237
Anemia: Disease of the Supra-renal Capsules.
1849. Thomas Addison, M.D. - - - - 239
On the Constitutional and Local Effects of Disease
of the Supra-renal Capsules. 1855. Thomas
Addison, M.D. - -- -- -- -- 244
r°m The ll orthtes of Cumberland, by Henry Lonsdale. London, 1 873
MEDICAL CLASSICS
vol. ii November, 1937 no. 3
Thomas Addison
English Physician, 1793—1860
BIOGRAPHY
1793 Born in April at Long Benton, near Newcastle. Educated
at Newcastle Grammar School.
1815 Age 22. Graduated with doctor’s degree in medicine
from University of Edinburgh, with thesis in Latin
“De Siphilide.” Became house surgeon to Lock Hos-
pital, London, and worked with the great dermatol-
ogist, Bateman.
1820 Age 27. Became associated with Guy’s Hospital, prob-
ably only as a student.
1 824 Age 3 1 . Appointed assistant physician at Guy’s Hospital.
1827 Age 34. Lectured on Materia Medica at the same in-
stitution.
1 829 Age 36. Wrote first book in English on action of poisons
on the living body.
1837 Age 42. Became physician to Guy’s Hospital and joint
lecturer on medicine with Dr. Richard Bright. First
used static electricity in treatment of spasmodic and
convulsive diseases.
1839 Age 46. Described appendicitis.
1849 Age 5^- Described pernicious anemia and disease of
the suprarenal capsules (melasma suprarenale or Ad-
dison’s disease), in a paper before the South London
Medical Society.
iS6d Age 67. Died on June 29, at Brighton, shortly after his
retirement. Buried in Lauercost Abbey, Cumberland.
234 Medical Classics
Addison’s reputation as a clinical teacher contributed perhaps
more than any of his colleagues, including Richard Bright, to the
fame of Guy’s Hospital as a school of medicine. His personality
v/as the exact opposite to Bright’s, being blunt, nervous, and
even arrogant to conceal his innate shyness.
EPONYMS
1. Anemia: Pernicious or Addison-Biermer. On the Conslitu-
tutional and Local Effects of Disease of the Suprarenal
Capsules , viii, 4 3 pp., 11 pi. fol., London, Highley, 1855.
Also in Collected Writings, New Sydenham Society, London,
1868, p. 212.
2. Disease: Chronic suprarenal insufficiency, usually due to
tuberculosis of suprarenal capsules. 1st announcement.
Anemia — disease of the suprarenal capsules. Lond. Med.
Gaz., n. s., 43: 517-518, 1849. Ist paper. On the Con-
stitutional and Local Effects of Disease of the Supra-renal
Capsules , viii, 43 pp., 11 pi. fob, London, Highley, 1855.
Also in Collected Writings, New Sydenham Society, London,
1868, pp. -209-239.
3. Keloid: Morphea. On the Keloid of Aliberl, and on frue
Keloid, 1S54.. Collected Writings, 1868, pp. 165-185.
4. Pill: Calomel, digitalis and squills for hepatic dropsy in
syphilis; called also Guy’s or Baillie’s pill.
BIBLIOGRAPHY OF WRITINGS
A — Army Medical Library.
B — New York State Library.
C — New York Academy of Medicine Library.
D — John Crerar Library of Chicago.
1. An essay on the operation of poisonous agents upon the’
living body. With John Morgan, viii, 91 pp., 8°, Lon-
don, Longman, 1829, in A.
2. Observations on the disorders of females connected with
uterine irritation, viii, 96 pp., 8°, London, Highley,
1830, in A & C. Also in: Collected Writings, 1868, pp.
109-154.
Thomas Addison 235
3. Observations on fatty degeneration of the liver. Guy’s
Hosp. Rep., 1 s., 1: 476-485, 1836.
4. Case of ovarian dropsy, removed by the accidental rupture
of the cyst. Ibid., 41-42.
5. On the influence of electricity as a remedy in certain con-
vulsive and spasmodic diseases. Ibid., 2: 493-507, 1837.
6. Observations on the diagnosis of pneumonia. Ibid., 57—67.
7. On the disorders of the brain, connected with diseased kid-
neys. Ibid., 4: 1-7, 1839.
8. Elements of the practice of medicine. With Richard Bright.
8°, London, 1839, A, C and D.
9. Observations on the anatomy of the lungs. (Read before
the Royal Med. & Surg. Soc., 1840.) In Collected Writ-
ings, 1868, pp. 1-6.
10. Observations on pneumonia and its consequences. Guy’s
Hosp. Rep., 2 s., 1: 365-402, 1843.
11. On the pathology of phthisis. Ibid., 3: 1-38, 1845.
12. On the difficulties and fallacies attending physical diagnosis
in diseases of the chest. Ibid., 4: 1-36, 1846. Also:
36 pp., 8°, London, 1846, in A.
13. Anemia — disease of the supra-renal capsules. Lond. Med.
Gaz., n. s., 43: 517-518, 1849.
14. On a certain affection of the skin, vitiligoidea — a. plana, b.
tuberosa, with remarks. With William Gull. Guy’s
Hosp. Rep., 2. s., 7: 265-276, 1851.
15. On the keloid of Alibert, or on true keloid. Med.-Chir.
Trans., Lond., 37: 27, 1854. Also in Collected Writ-
ings, 1868, pp. 165-185.
16. On the constitutional and local effects of disease of the
supra-renal capsules, viii, 43 pp., 11 pi., fob, London,
Highley, 1855, ' n -A an< ^ C. Also in Collected Writings,
1868, pp. 209-239.
(Same) Die Erkrankungen des Nebennieren und ihr Folgen.
Zum ersten Male in deutscher Ubersetzung herausgegeben
und eigeleitet von Erick Ebstein. 47 pp., 1 ph, 8°. Forms
No. 20 in Klassiker der Medizin, edited by K. Sudhoff.
Leipzig, Barth, 1912.
236 Medical Classics
(Same) A clinical study of Addison’s disease. Mayo Clinic
Monographs. By L. G. Rowntree and A. M. Snell.
Phila. Saunders, pp. 30-53, 1931-
17. A collection of the published writings of the late Thomas
Addison. By Dr. Wilks and Dr. Daldy. 239 pp., 8°,
London, New Sydenham Society, 1868, in A, B, C and D.
BIBLIOGRAPHY OF BIOGRAPHIES
Obituary. Med. Times & Gaz., 2: 20, i860.
Biography. The Worthies of Cumberland by Lonsdall, H.,
London, 4: 239, 1873.
Obituary. Guy’s Hosp. Gaz., 3: 193; 201, 1874.
Biography. Roll of the Royal College of Physicians, London.
2. ed.,3*.2o5, 1878.
Biography by Boase, F. Modem English Biography. London,
1882.
Biography. Eminent Doctors, Their Lives and Their Works by
Bethany, G. T., London, 1885.
Biography by Payne, J. F. Diet. Nat. Biog. London, I: 133,
1885.
Biography. Intercol. Med. Jour. Australas., Melbourne, 10:
212-215, 1905.
Biography. Guy’s Hosp. Gaz., 22: 520-524, 1908.
Biography by Winne, Jr., C. K. Albany Med. Ann., 29: 664-669,
1908.'
Biography by Ebstein, E. Munchen. med. Wochenschr., 59:
^3~3 8 > J 9 12 -
Biography; contributors to the science of medicine. Med. Jour.
& Rec., 120: 339-340, Oct. 1, 1924.
Biography by Hale-White, W., Guy’s Hosp. Rep., 76: 253-279,
July, 1926.
Doctor and patient in Addison’s journals. By Bragman, L. J.
Med. Jour. & Rec., 125: 483; 558, 1927.
Thomas Addison and Richard Bright, contemporaries. By
Oppenheimer, R. H. Ibid., 126: 20; 107, 1927.
Biography; Addison’s disease. Am. J. Surg., 8: 1312, 1930.
Biography. Colorado Med., 28: 420; 461, 1931.
Thomas Addison 237
Biography. Jour. Organotherapy, 16: 84, 1932.
Addison and his discovery of idiopathic anemia. By Long, E. R.,
Ann. Med. Hist., 7: 130-132, 1935.
Biography by Carbonero, R. Munoz. Cron, med., Valencia, 39:
953-954, 1935-
Biography in Great Doctors of the Nineteenth Century. By
Hale-White, Sir W. pp. 106-123, London, Arnold, 1935.
INDEX TO BIBLIOGRAPHY
Reference Year
Agents, poisonous 1 1829
Anemia 13 1849
Brain disorders with diseased kidneys 7 1839
Capsules, suprarenal 13 1849
16 1855
Chest, diagnosis 12 1846
Convulsions, electricity in 5 1837
Female disorders 2 1830
Keloid 15 1854
Kidney diseases 7 1839
Liver, fatty degeneration 3 1836
Lungs, anatomy of 9 1840
Medicine, practice of 8 1 839
Ovarian dropsy 4 1836
Phthisis 11 1845
Pneumonia 6 1 837
10 1843
Skin affection, vitiligoidea 14 1851
Spasmodic diseases, electricity in 5 1837
Supra-renal capsules 13 1849
16 1855
Uterine irritation 2 1830
Vilitigoidea 14 1851
ADDISON'S ANEMIA
Pernicious or Addison — Bienner anemia is described in a general, clinical way
in Addison's first announcement, Anemia, — disease of the supra-renal capsules ,
in Loud. Med- Gaz., m s,, 43: 517-518, 1S49. The author was attempting to find
an explanation for many cases of anemia which he had carefully studied and
followed- The description, although brief, dearly gives the clinical picture of
anemia but does not mention pigmentation of the skim In the three patients
who were examined after death, disease of the supra-renal capsules was found
In his paper On the Constitutional and Local Effects of Disease of the Supra-renal
Capsules (vin, 43 pp., n pi, fob, London, Highley, 1855), Addison writes:
"For a long period I had from time to time met with a remarkable form of gen-
eral anemia, occurring without any discoverable cause whatever — cases in which
there had been no previous loss of blood, no exhausting diarrhea, no chlorosis, no
purpura, no renal, splenic, miasmatic, glandular, strumous, or malignant disease.
Accordingly, in speaking of this form in clinical lecture, I perhaps with little
propriety applied to it the term ‘idiopathic/ to distinguish it from cases in which
there existed more or less evidence of some of the usual causes or concomitants of
the anemic state."
In the next seven paragraphs are described the characteristics of this "idio-
pathic" anemia but Addison concludes, "I have failed to discover any organic
lesion that could properly or reasonably be assigned as an adequate cause of such
serious consequences." The balance of the paper then concerns disease of the
supra-renal capsules.
Thus we see that Addison had recognized the importance of this "idiopathic"
anemia but was unable to throw much light on it. This great clinician deserves
to be remembered because he struggled to clear up the mysteries of the anemias
and, reaching the first mile-post, gave impetus to later workers.
Anton Bienner of Zurich in 1872 reported a series of cases of progressive per-
nations anemia. {Form ton progress': ten pemicioser Anomie, Cor.-Bl. f. schweiz.
Arzte, Basel, II: 15, 1872.) He was gven credit in Germany and France for
describing for the first time a new clinical condition. But just as he had been
preceded by Addison in 1855, so the latter had been anteceded by Combe in 1823,
by Andral in 3823, by Marshall Hall in 1837, Tiorry in 1841 and Pearce in 1845.
(French, H., in Allbutt and Rolleston, System of Medicine , London, Macmillan,
5:728, 1909.)
Anemia: Disease of the Supra-
renal Capsules
Published in The London Medical Gazette, n.s: 8: 517—5 1 S, 1849
R. ADDISON, at the request of the President,
proceeded to describe a remarkable form of
anemia, which, although incidently noticed by
various writers, had not attracted, as he
thought, by any means the attention it really
deserved. It was a state of general anemia
incident to adult males, and had for several years past been with
him a subject of earnest inquiry and of deep interest. It usually
occurs between the ages of twenty and sixty; sometimes proceed-
ing to an extreme degree in a few weeks, but more frequently
commencing insidiously, and proceeding very slowly, so as to
occupy a period of several weeks, or even months, before any
very serious alarm is taken either by the patient or by the
patient’s friends. Its approach is first indicated by a certain
amount of languor and restlessness, to which presently succeed a
manifest paleness of the countenance, loss of muscular strength,
general relaxation or feebleness of the whole frame, and indis-
position to, or incapacity for, bodily or mental exertion. These
symptoms go on increasing with greater or less rapidity: the face,
lips, conjunctivae, and external surface of the body, become more
and more bloodless; the tongue appears pale and flabby; the
heart’s action gets exceedingly enfeebled, with a weak, soft,
usually large, but always strikingly compressible pulse; the
appetite may or may not be lost; the patient experiences a dis-
tressing and increasing sense of helplessness and faintness; the
heart is excited, or rendered tumultuous in its action, the breath-
2 a.o Medical Classics
i
ine painfully hurried by the slightest exertion, whilst the whole
surface bears some resemblance to a bad wax figure; the patient
is no longer able to rise from his bed; slight edema perhaps shows
itself about the ankles; the feeling of faintness and weakness
becomes extreme, and he dies either from sheer exhaustion, or
death is preceded by signs of passive effusion or cerebral oppres-
sion. With all this, the emaciation or wasting of the body,
though sometimes considerable, is not unfrequently quite dis-
proportionate to the failure of the powers of the circulation —
relaxation and flabbiness, rather than wasting of the flesh, being
one of the most remarkable features of the disorder.
Dr. Addison next proceeded to give the details of several cases
which had fallen under his own immediate observation. In only
two of these did the patients recover: the one, a man below the
middle period of life, who was looked upon as past all hope, and
suspected to be suffering from some latent malignant disease,
slowly but steadily recovered under the free use of brandy, but
with the singular result of the hair of one side of his head turning
permanently grey, whilst the other retained its original brown
color. The second case of recovery occurred in a gentleman
above middle age: it was by no means far advanced, but was suffi-
ciently well marked to excite alarm. He left his business, quitted
London, and sought recreation in the country. After a time he
returned, and appeared to have shaken off the disorder almost
entirely. In three cases only was there an inspection of the body
after death, and in all of them was found a diseased condition of the
supra-renal capsules. In two of the cases no disease whatever
could be detected in any other part of the body. Dr. Addison
inquired if it were possible for all this to be merely coincidental?
It might be so, but he thought not, and making every allowance
for the bias and prejudice inseparable from the hope or vanity
of an original discovery, he confessed that he felt it very difficult
to be persuaded that it was so. On the contrary, he could not
help entertaining a very strong impression that these hitherto
mysterious bodies the supra-renal capsules — may be either
directly or indirectly concerned in sanguification; and that a
diseased condition of them, functional or structural, may inter-
Anemia
241
fere with the proper elaboration of the body generally, or of the
red particles more especially. At all events, he considered
that the time had arrived when he felt himself warranted in
directing the attention of the profession to these curious facts.
In thanking the Society for the patient hearing with which they
had favored him, he ventured to bespeak their interest not only
in regard to the anemia he had described, but also in cases of
purpura, and some of the more anemiated forms of chlorosis in
the female, which he could not but regard as being more or less
allied to the morbid state to which he had directed their atten-
tion. Indeed, not only had he found the anemia in question
occasionally occurring in connection with purpura, but had ob-
served in cases of the latter disorder certain local symptoms
which pointed somewhat significantly to the seat of the supra-
renal capsules; whilst the bloodless and waxy appearance of
certain chlorotic females bore so close a resemblance to the anemia
described, that it was difficult not to suspect the existence of
something common to both.
THE EXD
ADDISON’S DISEASE
For many years Thomas Addison had •studied the mysteries of
the anemias and had collected a series of cases of peculiar pigmen-
tation of the skin with languor and debility. After 29 years of
association with Guy’s Hospital and its “Great Men”, he made his
first announcement (see the attending pages) before the South
London Medical Society on pathologic changes in the suprarenal
capsules. Six years later, in 1855, Addison published a book of
43 pages and 1 1 plates, On the Constitutional and Local Effects 0/
Disease of the Suprarenal Capsules . This is reproduced here in
its entirety. He then recognized that disease of these organs was
always accompanied by changes in the pigmentation of the skin,
“a dark, dingy or smoky-looking discoloration”. He gives several
case histories with their complete necropsy findings. Although
the changes in the suprarenal gland are usually due to tuberculo-
sis, rarely there may be malignant metastases or unexplained
atrophy; Addison’s 11 case reports include some of these rare con-
ditions. We are not here concerned with his attempt to associate
such changes with the etiology of anemia but we must appreciate
Addison’s keen clinical observations and subsequent post-mortem
examinations. He was a pioneer in the study of suprarenal gland
pathology.
It was Armand Trousseau (1801-1867) who first proposed to
call the suprarenal syndrome, “Addison’s disease”. After re-
viewing the records of many cases, O. Brenner (Quart. Jour. Med.,
22: 1 21, 1928) concluded that the symptoms of Addison’s disease
occur only when most of the cortex is destroyed and even if the
suprarenal medulla and the chromaffin tissues are normal.
Recent progress in the treatment of Addison’s disease has con-
cerned the use of epinephrin to tolerance, the Muirhead regimen,
as reported by Dr. A. L. Muirhead, Professor of Pharmacology at
Creighton University College of Medicine, Omaha, in An auto-
graph history of a case of Addison's disease . (Jour. Amer. Med.
Assn., 76: 652-653, 1921.) Dr. Muirhead was treated in the Mayo
Clinic by Dr. L. G. Rowntree who, after Dr. Muirhead’s death,
reported Subsequent course of a case of Addison' s disease . (Ibid.*
79 : 19“.)
Renewed hope in therapy arose from the discovery by Swingle
and Pfiffner (Science, 71 : 321-322, 1930) that an extract of the
suprarenal cortex would maintain indefinitely the life of completely
suprarenalectomized cats. This material was used on patients
in the Mayo Clinic by Rowntree and his associates and reported
"strikingly effective in these cases and life saving in some”.
(Jour. Amer. Med. Assn., 96: 231 ; 97: 1446, 1931.)
Additional work has been done by J. M. Rogoff of Western
Reserve University School of Medicine, Cleveland, with "an ex-
tract representing the active substance or hormone (inter-renal in)
of the adrenal cortex". (Ibid., 92: 1569-1571; 99: 1309-1315,
1932.) "The outlook for relief — has been rendered more en-
couraging through the tentative indications, in the experiments of
Stewart, Rogoff and others, that replacement therapy may become
a reality". (Editorial, Ibid., 93: 1734, 1929.)
A test for the presence of Addison’s disease was suggested by
G. A. Harrop and his co-vrorkers. (Ibid., 100: 1850-1855, 1933.)
Signs of early relapse of Addison’s disease are produced by a re-
striction of sodium chloride. These signs usually appear between
the third and fifth day of the test. In the blood sodium and chlo-
ride are lowered, potassium and nitrogen are increased and there
is a diminution in the blood volume. After the signs arc es-
tablished prompt recovery follows intravenous administration of a
physiologic solution of sodium chloride. E. M. Kline has recently
demonstrated the value of this test. (Ibid., 108: 1592-1593,
J 937-)
Addison’s paper of 1855 is reproduced here by the kind per-
mission of the New York Academy of Medicine.
The plates in the original publication arc approximately 8 by
12 inches in size and are colored in the manner of 1855. In com-
parison to the standard of today, the color of the plates is un-
natural and exaggerated. They are therefore reproduced here
without color.
1
On the Constitutional and Local
Effects of Disease of the
Supra-renal Capsules
BY
THOMAS ADDISON, M.D.
Senior Physician to Guy* s Hospital
Published by Samuel HigHIe)*, London, 1855
To The Right Honourable Lord Hawke, as a tribute of
respect, and in grateful acknowledgment of a long, cordial,
and most disinterested friendship, this little work is dedica-
ted by His Lordship’s obliged friend and humble servant,
THOMAS ADDISON.
PREFACE
F PATHOLOGY be to disease what Physiology
is to health, it appears reasonable to conclude,
that in any given structure or organ, the laws
of the former will be as fixed and significant
as those of the latter; and that the peculiar
characters of any structure or organ may be as
certainly recognized in the phenomena of disease as in the phenom-
ena of health. When investigating the pathology of the lungs,
I was led, by the results of inflammation affecting the lung-tissue,
to infer, contrary to general belief, that the lining of the air-cells
was not identical and continuous with that of the bronchi; and
microscopic investigation has since demonstrated in a very strik-
ing manner the correctness of that inference, — an inference, be it
244
Disease of Supra-Renal Capsules 24.5
observed, drawn entirely from the indications furnished by path-
ology. Although Pathology therefore, as a branch of medical
science, is necessarily founded on Physiology, questions may
nevertheless arise regarding the true character of a structure or
organ, to which occasionally the pathologist may be able to return
a more satisfactory and decisive reply than the physiologist, —
these two branches of medical knowledge being thus found mu-
tually to advance and illustrate each other. Indeed, as regards
the functions of individual organs, the mutual aids of these two
branches of knowledge are probably much more nearly balanced
than many may be disposed to admit; for in estimating them, we
arc very apt to forget how large an amount of our present physi-
ological knowledge, respecting the functions of these organs, has
been the immediate result of casual observations made on the
effects of disease. Most of the important organs of the body,
however, are so amenable to direct observation and experiment,
that in respect to them the modern physiologist may fairly lay
claim to a large preponderance of importance, not only in estab-
lishing the solid foundation, but in raising and greatly strength-
ening the superstructure of a rational pathology. There are still,
however, certain organs of the body, the actual functions and
influence of which have hitherto entirely eluded the researches
and bid defiance to the united efforts of both physiologist and
pathologist. Of these not the least remarkable arc the “Supra-
Rcnal Capsules,” — the Atrabiliary Capsules of Caspar Bartho-
linus; and it is as a first and feeble step towards an inquiry into
the functions and influence of these organs, suggested by Path-
olocv, that I now put forth the followinc paces.
T. A.
£4 New Street, Spring Gardens,
May 21, 1S55.
It will hardly be disputed that at the present moment, the
functions of the suprn-rcnal capsules, and the influence they
exercise in the general economy, are almost or altogether un-
known. The large supply of blood which they receive from three
246 Medical Classics
separate sources; their numerous nerves, derived immediately
from the semilunar ganglia and solar plexus; their early develop-
ment in the foetus; their unimpaired integrity to the latest period
of life; and their peculiar gland-like structure; all point to the
performance of some important office: nevertheless, beyond an
ill-defined impression, founded on a consideration of their ul-
timate organization, that, in common with the spleen, thymus
and thyroid body, they in some way or other minister to the
elaboration of the blood, I am not aware that any modern author-
ity has ventured to assign to them any special function or influence
whatever.
To the physiologist and to the scientific anatomist, therefore,
they continue to be objects of deep interest, and doubtless both
the physiologist and anatomist will be inclined to welcome, and
regard with indulgence, the smallest contribution calculated to
open out any new source of inquiry (p. 2) respecting them. But
if the obscurity, which at present so entirely conceals from us the
uses of these organs, justify the feeblest attempt to add to our
scanty stock of knowledge, it is not less true, on the other hand,
that any one presuming to make such an attempt, ought to take
care that he do not, by hasty pretensions, or by partial and prej-
udiced observation, or by an over-statement of facts, incur the
just rebuke of those possessing a sounder and more dispassionate
judgement than himself. Under the influence of these considera-
tions I have for a considerable period withheld, and now venture
to publish, the few facts bearing upon the subject that have fallen
within my own knowledge; believing as I now do, that these con-
curring facts, in relation to each other, are not merely casual
coincidences, but are such as admit of a fair and logical inference —
an inference, that where these concurrent facts are observed, we
may pronounce with considerable confidence, the existence of
diseased supra-renal capsules.
As a preface to my subject, it may not be altogether without
interest or unprofitable, to give a brief narrative of the circum-
stances and observations by which I have been led to my present
convictions.
For a long period I had from time to time met with a very re-
markable form of general anaemia, occurring without any dis-
Disease of Supra-Renal Capsules 247
covcrablc cause whatever; cases in which there had been no
previous loss of blood, no exhausting diarrhoea, no chlorosis, no
purpura, no renal, splenic, miasmatic, glandular, strumous, or
malignant disease. Accordingly, in speaking of this form of
anaemia in clinical lecture, I, perhaps with little propriety, applied
to it the term “idiopathic,” to distinguish it from cases in which
there existed more or less evidence of some of the usual causes
or concomitants of the anaemic state.
The disease presented in every instance the same general char-
acter, pursued a similar course, and, with scarcely a single excep-
tion, was followed, after a variable period, by the same fatal re-
sult. It occurs in both sexes, generally, but not exclusively,
beyond the middle period of life, and so far as I at present know,
chiefly in persons of a somewhat (p. 3) large and bulky frame, and
with a strongly-marked tendency to the formation of fat. It
makes its approach in so slow and insidious a manner, that the
patient can hardly fix a date to his earliest feeling of that languor,
which is shortly to become so extreme. The countenance gets
pale, the whites of the eyes become pearly, the general frame
flabby rather than wasted; the pulse perhaps large, but remark-
ably soft and compressible, and occasionally with a slight jerk,
especially under the slightest excitement; there is an increasing
indisposition to exertion, with an uncomfortable feeling of faint-
ness or breathlessness on attempting it; the heart is readily made
to palpitate; the whole surface of the body presents a blanched,
smooth and waxy appearance; the lips, gums and tongue seem
bloodless; the flabbiness of the solids increases; the appetite fails;
extreme languor and faintness supervene, breathlessness and
palpitations being produced by the most trifling exertion or emo-
tion; some slight ccdcma is probably perceived about the ankles;
the debility becomes extreme, the patient can no longer rise from
his bed, the mind occasionally wanders, he falls into a prostrate
and half-torp:d state, and at length expires: nevertheless to the
very last, and after a sickness of perhaps several months’ dura-
tion, the bulkincss of the general frame and the amount of oberity
often present a most striking contrast to the failure and exhaus-
tion observable in every other respect.
With, perhaps, a single exception, the disease, in
mv own ex-
2a 8 Medical Classics *
i
perience, resisted all remedial efforts, and sooner or later ter-
minated fatally. On examining the bodies of such patients after
death, I have failed to discover any organic lesion that could
properly or reasonably be assigned as an adequate cause of such
serious consequences; nevertheless, from the disease having uni-
formly occurred in fat people, I was naturally led to entertain a
suspicion that some form of fatty degeneration might have a
share at least in its production; and I may observe, that in the
case last examined, the heart had undergone such a change, and
that a portion of the semilunar ganglion and solar plexus, on
being subjected to microscopic examination, was pronounced by
Mr. Quekett to have passed into a (p. 4) corresponding condition.
Whether any, or all, of these morbid changes are essentially con-
cerned, as I believe they are, in giving rise to this very remarkable
disease, future observation will probably decide.
The cases having occurred prior to the publication of Dr.
Bennett’s interesting essay on “Leucocythasmia,” it was not
determined by microscopic examination whether there did, or did
not, exist an excess of white corpuscles in the blood of such
patients.
It was whilst seeking in vain to throw some additional light
upon this form of anaemia, that I stumbled upon the curious
facts, which it is my more immediate object now to make known
to the Profession; and however unimportant or unsatisfactory
they may at first sight appear, I cannot but indulge the hope,
that by attracting the attention and enlisting the cooperation of
the Profession at large, they may lead to the subject being prop-
erly examined and sifted, and the inquiry so extended, as to
suggest, at least, some interesting physiological speculations, if
not still more important practical indications.
The leading and characteristic features of the morbid state to
which I would direct attention, are, ansemia, general languor and
debility, remarkable feebleness of the heart’s action, irritability
of the stomach, and a peculiar change of colour in the skin, oc-
curring in connexion with a diseased condition of the “supra-
renal capsules.”
As has been observed in other forms of anaemic disease, this
Disease of Supra-Renal Capsules 249
singular disorder usually commences in such a manner, that the
individual has considerable difficulty in assigning the number of
weeks or even months that have elapsed since he first experienced
indications of failing health and strength; the rapidity, however,
with which the morbid change takes place, varies in different
instances. In some cases that rapidity is very great, a few weeks
proving sufficient to break up the powers of the constitution, or
even to destroy life; the result, I believe, being determined by the
extent, and by the more or less speedy development, of the or-
ganic lesion. The patient, in most of the cases I have seen, has
been observed gradually to fall off in general health; he becomes
languid (p. 5) and weak, indisposed to either bodily or mental
exertion; the appetite is impaired or entirely lost; the whites of
the eyes become pearly; the pulse small and feeble, or perhaps
somewhat large, but excessively soft and compressible; the body
wastes, without, however, presenting the dry and shrivelled skin,
and extreme emaciation, usually attendant on protracted malig-
nant disease; slight pain or uneasiness is from time to time referred
to the region of the stomach, and there is occasionally actual
vomiting, which in' one instance was both urgent and distressing;
and it is by no means uncommon for the patient to manifest
indications of disturbed cerebral circulation. Notwithstanding
these unequivocal signs of feeble circulation, anaemia, and general
prostration, neither the most diligent inquiry, nor the most care-
ful physical examination, tends to throw the slightest gleam of
light upon the precise nature of the patient’s malady: nor do we
succeed in fixing upon any special lesion as the cause of this
gradual and extraordinary constitutional change. We may in-
deed suspect some malignant or strumous disease; we may be led
to inquire into the condition of the so-called blood-making or-
gans; but we discover no proof of organic change anywhere, —
no enlargement of spleen, thyroid, thymus or lymphatic glands,
— no evidence of renal disease, of purpura, of previous exhausting
diarrhoea, or ague, or any long-continued exposure to miasmatic
influences: but with a more or less manifestation of the symptoms
already enumerated, we discover a most remarkable, and, so far
as I know, characteristic discoloration taking place in the skin, —
250 Medical Classics
sufficiently marked indeed as generally to have attracted the
attention of the patient himself, or of the patient’s friends. This
discoloration pervades the whole surface of the body, but is com-
monly most strongly manifested on the face, neck, superior ex-
tremities, penis and scrotum, and in the flexures of the axillae
and around the navel. It may be said to present a dingy or
smoky appearance, or various tints or shades of deep amber or
chestnut-brown; and in one instance the skin was so universally
and so deeply darkened, that, but for the features, the patient
might have been mistaken for a mulatto.
(p. 6) In some cases this discoloration occurs in patches, or
perhaps rather certain parts are so much darker than others,
as to impart to the surface a mottled or somewhat checkered
appearance; and in one instance there were, in the midst of this
dark mottling, certain insular portions of the integument pre-
senting a blanched or morbidly white appearance, either in con-
sequence of these portions having remained altogether unaffected
by the disease, and thereby contrasting strongly with the
surrounding skin, or, as I believe, from an actual defect of colour-
ing matter in these parts. Indeed, as will appear in the subse-
quent cases, this irregular distribution of pigment-cells is by no
means limited to the integument, but is occasionally also made
manifest on some of the internal structures. We have seen it in
the form of small black spots, beneath the peritoneum of the
mesentery and omentum — a form which in one instance presented
itself on the skin of the abdomen.
This singular discoloration usually increases with the advance
of the disease; the ansemia, languor, failure of appetite, and feeble-
ness of the heart, become aggravated; a darkish streak usually
appears upon the commissure of the lips; the body wastes, but
without the extreme emaciation and dry harsh condition of the
surface so commonly observed in ordinary malignant diseases;
the pulse becomes smaller and weaker, and without any special
complaint of pain or uneasiness, the patient at length gradually
sinks and expires. In one case, which may be said to have been
acute in its development as well as rapid in its course, and in
which both capsules were found universally diseased after death,
Disease of Supra-Renal Capsules 251
the mottled or checkered discoloration was very manifest, the
ansemic condition strongly marked, and the sickness and vomiting
urgent; but the pulse, instead of being small and feeble as usual,
was large, soft, extremely compressible, and jerking on the slight-
est exertion or emotion, and the patient speedily died.
My experience, though necessarily limited, leads to a belief
that the disease is by no means of very rare occurrence, and that
were we better acquainted with its symptoms and progress, we
should probably succeed (p. 7) in detecting many cases, which,
in the present state of our knowledge, may be entirely overlooked
or misunderstood; and, I think, I may with some confidence
affirm, that although partial disease of the capsules may give
rise to symptoms, and to a condition of the general system, ex-
tremely equivocal and inconclusive, yet that a more extensive
lesion will be found to produce a state, which may not only create
a suspicion, but be pronounced with some confidence to arise
from the lesion in question. When the lesion is acute and rapid,
I believe the anaemia, prostration, and peculiar condition of the
skin will present a corresponding character, and that whether
acute or chronic, provided the lesion involve the entire structure
of both organs, death will inevitably be the consequence.
If this statement be correct, and I quite believe it to be so, the
chief difficulty that remains to be surmounted by further experi-
ence in this, I fear, irremediable disease, is a correct and certain
diagnosis; — how we may at the earliest possible period detect the
existence of this form of ansemia, and how it is to be distinguished
from other forms of ansemic disorder. As I have already ob-
served, the great distinctive mark of this form of anaemia is the
singular dingy or dark discoloration of the skin; nevertheless at a
very early period of the disorder, and when the capsules are less
extensively diseased, the discoloration may, doubtless, be so
slight and equivocal as to render the source of the anaemic con-
dition uncertain. Our doubts, in such cases, will have reference
chiefly to the sallow anaemic conditions resulting from miasmatic
poisoning or malignant visceral disease; but a searching inquiry
into the history of the case, and a careful examination of the
several parts or organs usually involved in anaemic disease, will
Medical Classics
252
furnish a considerable amount of at least negative evidence; and
when we fail to discover any of the other well-known sources of
that condition, when the attendant symptoms resemble those
numerated as accompanying disease of the capsules, and when
to all this is superadded a dark, dingy or smoky-looking dis-
coloration of the integument, we shall be justified at least in
entertaining a strong suspicion in some instances, — a suspicion
almost amounting to certainty in others. It must, however,
(p. 8) be observed, that every tinge of yellow, or mere sallowness,
throws a still greater doubt over the true nature of the case, and
that the more decidedly the discoloration partakes of the char-
acter described, the stronger ought to be our impression as to the
capsular origin of the disorder.
The morbid appearances discovered after death will be de-
scribed with the cases in which they occurred; but I may remark
that a recent dissection (March 1855) has shown that even malig-
nant disease may exist in both capsules, without giving rise to
any marked discoloration of the skin; but, in the case alluded to,
the deposit in each capsule was exceedingly minute, and could
not have seriously interfered with the functions of the organs:
extensive and fatal malignant disease had, however, affected
other parts. It may be observed in conclusion, that on subject-
ing the blood of a patient, who recently died from a well-marked
attack of this singular disease, to microscopic examination, a
considerable excess of white corpuscles was found to be present.
p. 9 CASE l * — REPORTED BV MR. THOMAS FULLER
James TV 1 ootten, set. 32, admitted into Guy’s Hospital, under
Dr. Golding Bird, Feb. 6, 1850, has been residing .at Long Alley,
Moorfields, and is by occupation a baker. States that he was
attacked with a cough three years since, which he was unable to
get rid of by ordinary remedies, and was finally cured at St.
Bartholomew’s, after taking pills for one week. From this time,
his skin, previously white, began to assume a darker hue, which
has been gradually increasing. Twelve months after leaving the
The cases generally are given in the language and style of their respective
reporters.
Disease of Supra-Renal Capsules 253
above hospital he was laid up from excessive weakness, the result
of his cough, which had again appeared, and incapacitated him
for his work. He now became an out-patient of St. Thomas’s,
under Dr. Goolden, who cured his cough, and thinking that the
colour of his skin depended on jaundice, treated him for that dis-
ease, but to no purpose. He left the hospital in tolerable health,
but subsequently lost flesh, and became so excessively weak, the
colour of his skin at the same time getting rapidly darker, that he
applied for admission here, which was granted him.
Present Appearances . — The whole of the skin on the body is
now of a dark hue, and he has just the appearance of having
descended from coloured parents, which he assures me is not the
case, nor have any of his family for generations, that he can an-
swer for, manifested this peculiarity. The colour of the skin
does not at all resemble that produced by the absorption of the
nitrate of silver, but has more the appearance of the pigment of
the choroid of the eye; it seems to have affected some parts of
his body more than others, the scrotum and penis being the dark-
est, the soles of the feet and palms of the hands the lightest; the
cheeks are a little sunken, the nose is pointed, the conjunctive are
of a pearly (p. io) whiteness; the voice is puny and puerile, the
patient speaking with a kind of indescribable whine, and his
whole demeanour is childish. He complains of a sense of soreness
in the chest about the scrobiculus cordis. The chest is well-
formed and perfectly resonant; the sounds of the heart are also
healthy; there is some slight fullness in the region of the stomach.
The urine is of a proper colour, and he has passed in twelve hours
one and a half pint, which has a specific gravity 1008, an acid
reaction, and contains neither albumen nor sugar; there is also
some pain on pressure in the left lumbar region.
Feb. 8. — Dr. Bird wished a likeness to be taken, so as to be able
to watch any alterations in his colour; and considering the case
one of anaemia, ordered Syr. Ferri Iodidi 3j ter die; and middle
diet. These he took the whole of the time that he was in the
hospital, and was discharged in April, rather stronger, but the
colour remaining precisely the same.
254 Medical Classics
Shortly after his discharge from the hospital, he was seized with
acute pericarditis and pulmonic inflammation, under which he
speedily sank and died.
The following is a report of the post-mortem examination: —
Lungs universally adherent, the adhesions being very old. The
upper lobe of the right lung contained some small defined patches
of recent pneumonia, about the size of a crown-piece, surrounded
by tolerably healthy structure. The lower lobe was extremely
fleshy and without air. The left lung was bound down by old
pleuritic adhesions, which were very tough and difficult to be
tom through. The substance of this lung was fleshy, and con-
tained but little air. There was no tubercle or cavity. The
mucous membrane of the bronchial tubes was considerably in-
jected, and, I believe, rather thickened. The pericardium was
distended with fluid of a deep brown colour, amounting to about
half-a-pint; recent lymph was effused over the whole serous sur-
face. The liver and spleen were (p. n) both of weak texture,
and easily broken down; the structure of the liver rather coarse.
The gall-ducts pervious. The gall-bladder contained the usual
quantity of bile, which was thin, watery and clear. The thoracic
duct was pervious throughout; and there was no obstruction to
any of the veins or arteries that I could discover. The colour of
the blood m the arteries had an unusually dark appearance. The
kidneys were quite healthy and of full size. The supra-renal
capsules were diseased on both sides, the left about the size of a
hen’s egg, with the head of the pancreas firmly tied down to it
by adhesions. Both capsules were as hard as stones. Intestines
pale. Lumbar glands natural. No tubercular deposit was dis-
covered in any organ. The head was not examined. (Vide PI. I.)
In some of the cases about to be given, the capsules merely
participated in disease affecting other organs, either of a strumous
or malignant character, and it might consequently be doubtful
whether the peculiar symptoms depended upon such complica-
tions, or upon the special disease of the capsules.
In the above instance, however, no such doubt could reasonably
Disease of Supra-Renal Capsules 255
be entertained, inasmuch as there was found no abnormal con-
dition whatever of any other organ, to which these peculiar symp-
toms could by any means be attributed. The slow and gradual
inroads of the disease, and the remarkable excess of pigment, were
sufficiently accounted for by the universality of the change that
had taken place in the structure of both capsules; at least such
would be the legitimate conclusion to be drawn from a comparison
of the present with other cases about to be related.
(p. 12) CASE 11
James Jackson, set. 35. The subject of this case was admitted
into the Clinical ward, under my own care, November n, 1851,
and died December 7, 1851. For the particulars of its history
and result, I am indebted to my former pupil and present dis-
tinguished colleague. Dr. Gull, who was the first to suspect the
true nature of the malady during the life of the patient.
A married man, residing at Gravesend, and occupied as a tide-
waiter in the Customs. Of a bilious temperament, dark hair
and sallow complexion, which since his illness has much deepened,
so that now it is of a dark olive-brown. His wife says, “This
obvious change in his complexion has been from the beginning of
his illness, and gradually came on at that time.”
There can be no doubt as to this change in the complexion
depending upon increase of pigment, for if the lips be turned
down, the mucous membrane is seen to be mottled by a deposit
of pigment, and a closer examination shows that the dark colour
of the lips, which at first had the appearance of sordes, is depend-
ent upon the presence of a black pigment, which is not movable
by moistening or washing the lips. There is an expression of
anxiety in the face, and the brow is contracted. He gives the
following history of himself: —
His occupation subjects him to much anxiety; he is exposed to
all the vicissitudes of the weather, both night and day, and some-
times his food for weeks together consists of salt provisions.
Eight years ago he had rheumatism, accompanied with great
nervous depression; since that time he has enjoyed general good
256 Medical Classics
health, with the exception of some attacks of (p. 13) bilious
vomiting. His present illness came on six months ago with
headache, vomiting and constipation. About the sixth day of
his illness he became delirious, and was insensible for twenty-
four hours. On recovering his consciousness, he was unable to
move the fingers of either hand, nor could he move the legs below
the knees; the same parts were numb, as was also the tip of the
tongue. He continued weak during the whole summer.
Two months ago he resumed his occupation, and remained at
it until ten days back, when the old symptoms of headache, vom-
iting and constipation returned. Dr. McWilliam saw him at this
time, and found his symptoms to have an intermittent character,
and regarded the case as one of miasmatic poisoning, not only
from his general symptoms, but also from the dark poisoned look
of his face, not altogether unlike that presented on the approach
of the asphyxic stage of cholera.
On his admission into the hospital, the pulse was extremely
small and feeble, the expression of the face pinched, the brows
knitted. He vomited mucus containing altered blood of a dark
brown colour; tongue clean; epigastric region full, especially
towards the left side, where he has had some twitching pain and
slight tenderness on pressure. Urine natural in colour and quan-
tity, of a light brown colour, not coagulable by heat. He went
on, day by day, with but slight symptoms of change. Skin cool;
pulse moderate in frequency, but extremely feeble, so as scarcely
to be felt at the wrist. On several occasions the depression was so
great as to require the exhibition of decided stimulants. There
was a continued tendency to sickness. The abdomen soft, with
marked aortic pulsation. Bowels constipated; chest everywhere
resonant; heart’s sounds normal; extent of dullness on percussion
not increased. Slight traces of intermittence in the symptoms;
the surface in the evening being cool, or even cold, and the fol-
lowing morning warm, as if from reaction.
Probable diagnosis . — The epigastric tenderness and pulsation,
with frequent vomiting, and the ejected mucus and altered blood,
point to an inflammatory condition of the gastric mucous mem-
brane. But what (p. 1 4) condition of system is it which favours
Disease of Supra-Renal Capsules 257
the production of black pigment? Is it some affection of the
liver; or is it, as Dr. Addison supposes, disease of the supra-renal
capsules ?
Sectio Cadaveris
The lining membrane of the stomach was finely injected into
minute puncta and stellse of a bright red colour, with two or
three spots of ecchymosis. The structure of the membrane was
thickened and pulpy, and the surface covered with tenacious
mucus. In some parts there were irregular superficial abrasions;
these appearances of the mucous membrane becoming very dis-
tinct by examining it under water by aid of sunlight, and seeming,
moreover, unequivocally to demonstrate the existence of a gas-
tritis. The brain, lungs, heart, spleen, liver and kidneys were
normal.
. The supra-renal capsules contained both of them compact
fibrinous concretions, seated in the structure of the organ;
superficially examined they were not unlike some forms of stru-
mous tubercle. (Vide PI. II. and PI. VIII. figs. 4, 5.)
The slow and insidious approach and progress of the constitu-
tional loss of strength, the extreme feebleness of the pulse, the
absence of all evidence of any lesion sufficient to account for the
patient’s declining condition, the loss of appetite, the uneasiness
and irritability of the stomach, and the indications of disturbed
cerebral circulation, were all so strongly marked, and so exactly
corresponded in kind with what have been observed to accompany
the most extensive disease of the capsules, that, coupled with
the excess of dark pigment in the integument, we did not hesitate
to anticipate with much confidence an extensively diseased con-
dition of these organs.
p. 15 CASE III. — REPORTED BY MR. WILLIAMS
Henry Patten, set. 26, a carpenter and window-blind maker,
residing at 13 Brandon Street, Walworth, was admitted Nov. 9,
1854, having been for some time an out-patient under Dr. Rees.
His habits have been somewhat intemperate; his drink chiefly
258 ' Medical Classics
malt liquor and spirits. With the exception of a sister, who died
of phthisis, all his relations are healthy. He has been married
four years. The patient states that up to six months ago, he
enjoyed very good health, but then began to be troubled with
what he calls “rheumatic” pains in the right leg, which, without
laying him up, gradually extended to his hips and side, and thence
to the bottom of the spine. His back latterly has been very
tender, a jerk or jarring movement giving him great pain at that
part. He has noticed his lips to have become dark-coloured for
the last three months, and more lately his face to be similarly
discoloured in patches. For the last month he has discontinued
work on account of attacks of giddiness and dimness of sight,
accompanied by a peculiar pain at the back of the head and par-
tial loss of consciousness. These attacks would occur several
times in the course of the day, upon any unusual exertion, always
whilst in the standing posture, and were instantly relieved by
sitting or lying down. Since he has discontinued his employment,
they have only occurred on getting out of bed in the morning.
It is for the pains and tenderness at the back, and occasional
attacks, as above described, with general debility, that he has
been attending this hospital as an out-patient.
Present condition . — The patient presents a highly strumous
appearance, being thin, pale, and the hair dark and dry. Over
the face and forehead, which are of a general yellowish hue, are
several patches of darkened (p. 1 6) skin, and similar black patches
on the lips. There is angular curvature at the second, and great
tenderness on pressure over the upper three lumbar vertebrae; he
complains also of pain at this part upon moving in bed. There
is no paralysis, but considerable general debility. His bowels
are regular, and the tongue clean, but the appetite is impaired;
the urine is clear, moderate in quantity, and not albuminous.
Heartsounds normal, but the impulse feeble. Pulse 80, small
and weak.
Nov. 10th. P f Quinae Disulph. gr. iss.
Aquae distill. §j-
Syr. Rhoeados 3ss.
Acid. Sulph. dil. m. v.
Ft. Haustus ter die s.-Vin. Alb. §iv.
Disease of Supra-Renal Capsules 259
With these medicines and middle diet he continued with no
appreciable change until the 24th, when he had a kind of fainting
fit upon rising to have his bed made, contrary to an order that
he should keep in the recumbent posture. This day his diet was
changed to milk, at his own request. He has been once or twice
sick after taking his food.
28th. — The sickness has continued, and he today has a trouble-
some hiccough, for which he was ordered
Jul. Ammon, p. r. n.
29th. — He has had little sleep, the hiccough, unrelieved by
the Julep. Ammon., annoying him much. Dr. Barlow, who now
took the ward, ordered him
yEther. Chlor. m. v.
Vini Opii m. v.
ex Mist. Camph. t. d. s.
30th. — He is today about the same. Has been sick this morn-
ing, the vomited matter consisting of food and drink. The hic-
cough occasionally ceasing.
Dec. 1st. — Hiccough still very harassing.
B Vini Opii m. x.
Tinct. Castorei m. x.
ex Julep. Pimentse p. r. n.
(p. 17) This. was found to relieve the hiccough somewhat.
2nd. — He seems considerably weaker, and upon approaching
him, his eyelids, half-closed, allowed the lower sclerotic of the
raised eyeballs to be seen. The tongue was moist and clean, and
pulse 80, very weak. On speaking to him he roused up and ap-
peared quite as usual, but soon relapsed into the torpid, state
again. His blood under the J-inch object-glass presented from
forty to sixty white corpuscles in each field, mostly scattered
about, but some in patches of two or three and six or eight to-
gether.
3rd. — Slept better, although the hiccough did not cease. He
complains of a constricting pain about the waist; he is tender on
pressure over the spleen, where no tumour is to be felt. The
tongue today is dry, and beginning to be sordid, teeth dirty,
pulse weak. He presents the same typhoid appearances.
4th. — Pulse weaker, dicrotic, 96; roused from the torpid state
260 Medical Classics
with more difficulty than yesterday. He talks very sensibly,
but his wife, who watches by his bedside, states that he wanders
in the night.
Jul. Ammon, c. Tinct. Castorei m. v. p. r. n.
The blood presented the same appearances under the micro-
scope as before.
5th. — Hiccough continues, is more feeble, pulse scarcely per-
ceptible, lies in a torpid and typhoid state. When roused, said
he was sore all over the body. Tongue and teeth sordid.
6th. — Died quietly at 5 A - M *
Sectio Cadaveris
Nine and a half hours after death in cold wet weather. Rigor
mortis, but no decomposition. There was not much emaciation,
and the axilla; were slightly discoloured. The countenance was
paler than in life, but presented the same olive hue, with the
dark patches on the face, forehead and lips. There was a psoas
abscess on the right side, extending from Poupart’s ligament to
the diseased vertebrae, and holding about a pint of flaky pus.
(p. 18.)
The disease was between the first and second vertebrae, com-
mencing in the cartilage, and nearly destroying the neighbouring
vertebrae at their centres. The bone surrounding the cavity was
red, soft, and infiltrated with strumous matter.
Pleura and bronchi healthy.
Both lungs contained hard masses of grey strumous pneumonic
deposit, mostly in the apices, but also in the lower lobes; these
masses presented the appearance of a conglomeration of tubercles,
held together by inflammatory matter. Heart and pericardium
healthy. Heart’s weight 7§ oz. The blood on microscopic
examination contained the same excess of white corpuscles ob-
served in life. Stomach healthy, slightly adherent to the left
supra-renal capsule; its structure was not affected. Spleen large,
firm, oz. in weight. Corpuscles visible. The pancreas and
all other abdominal organs were healthy. The head was not
examined.
Each supra-renal capsule was completely destroyed and con-
verted into a mass of strumous disease, the latter of all degrees of
Disease of Supra-Renal Capsules 261
consistency. The left supra-renal capsule had formed at the
upper part a close connexion with the outer coat of the stomach.
The upper part of this capsule seemed fluid, and of the colour of
pus; the lower firmer, and of the consistency of putty. The right
capsule had all degrees of consistency from the bottom to the
top; the lower part almost fluid and resembling pus, the centre
putty-like, and above this the matter could be detached in flakes;
and at the top it was quite earthy, separate angular pieces being
easily detached. Vide Plates III. and IV.
Although this patient was known to be labouring under a
serious affection of the spine, the ordinary indications of disease
of the suprarenal capsules were sufficiently prominent to justify
the prediction, which was so satisfactorily confirmed by the post-
mortem examination. It is also worthy of remark, that although
the patient, as usual, suffered considerably from irritability of
stomach, there was but little change observable in that organ
after death.
p. 19 CASE IV. — REPORTED BY THE WARD CLERK
"John Iveson, set. 22, admitted into Guy’s Hospital, March 20,
•1854, and died the following day. A stonemason, residing at
Lambeth. Last winter he had pain in the stomach and vomiting.
He slightly improved, but the day after Christmas was confined
to his bed with great pain and vomiting; the vomited matter
consisting of a watery fluid. At that time he had “tic doulou-
reux.” On admission his extremities were cold, he was almost
pulseless, his hands were blue; he had not had any diarrhoea; he
had slight pain, or rather soreness in the hypogastric region; he
was quite sensible; the pupils were much dilated. He rallied a
little after his admission; had no purging, but vomited bilious
matter; had no diabetes or albumenuria. He appeared to die
from syncope.
Sectio Cadaveris
Seventeen hours after death, weather cold, limbs rigid, body
tolerably nourished, face of a dingy colour, also the axillae and
hands. Abdomen not distended.
262 Medical Classics
Head . — The dura mater and sinuses were found to be healthy,
the membranes injected and the veins full. There was slight
subarachnoid effusion. The grey matter of the cerebrum was
rather deep in colour. The brain was in other respects normal.
Chest . — Trachea granular and congested. The right pleura
adherent at the posterior and lower parts; on the left side there
were firm adhesions at the apex. The bronchi granular; the
left apex was a little puckered, and presented several lobules,
with iron-grey consolidation and calcareous deposit. The right
lung was healthy, with the exception of a single (p. 20) iron-
grey consolidation at the apex. The bronchial and mediastinal
glands were healthy.
Heart . — Pericardium healthy. There was a white patch on
the right ventricle. The right side of the heart was moderately
distended with clot, the left entirely and firmly contracted. The
valves were healthy, and the muscular fibre, though flaccid, ap-
peared healthy. No fat was found about the heart. Weight
7 oz.
Abdomen . — Peritoneum healthy, viscera moderately contrac-
ted. Stomach not distended; at the cardiac extremity there was
post-mortem solution of the mucous membrane: towards the
lesser curvature it was granular, in some parts destroyed, ul-
cerated; quite superficially there was arborescent injection. On
microscopical examination, mucous and granule-cells were ob-
served. Brunner’s glands were very prominent. Ileum with
much mucous congestion. Peyer’s and solitary glands very dis-
tinct, but only hypertrophied. The mesenteric glands were en-
larged, firm and white, full of nuclei, hypertrophied.
Large intestines were healthy.
Liver was of normal form and condition; there was a small
amount of fat in the cells; weight 2 lbs. 14 oz., containing no ar-
senic. Gall-bladder healthy; ducts free, but not enlarged.
Spleen enlarged, weight 6 oz. Pancreas was healthy.
The two supra-renal capsules together weighed 49 grains; they
appeared exceedingly small and atrophied; the right one was
natural, firm; the left deformed by contraction; each adherent
to surrounding parts by dense areolar tissue. The section gave a
Disease of Supra-Renal Capsules 263
pale and homogeneous aspect; it presented a fibrous tissue, fat
and cells about the size of white blood-corpuscles. The lumbar
glands were enlarged. The kidneys coarse, weighing 10 oz.
The bladder and prostate were healthy. Vide Plate V.
The history of this man’s case renders it probable that his
disease commenced several months prior to his admission into
the hospital, and it is not a little remarkable that his earliest com-
plaint was of sickness, (p. ai) vomiting and pain in the region of
the stomach; symptoms which have constituted a more or less
prominent feature in every case that has fallen under my notice,
and which in the present instance were so urgent as to suggest
a suspicion of some acrid poison having been received into the
stomach.
How far these gastric symptoms when present are referrible
to sympathy existing between the diseased capsules and the
stomach — how far they depend upon disturbed circulation within
the head — how far they are attributable to accidental or essential
gastric inflammation — and how far the inflammatory aspect of
the gastric mucous membrane is the mere result of severe and
repeated vomiting, a more extended observation will probably
determine hereafter. It was from the presence of these gastric
symptoms, the extreme and peculiar prostration of the patient’s
strength, the great feebleness and smallness of the pulse, the
ansemiated eye, the absence of any discoverable lesion to account
for the patient’s condition, and more especially the dingy dis-
coloration of the face, that led before death to a belief that we
should on post-mortem examination find disease of the supra-
renal capsules.
It is, moreover, of some significance and importance to observe,
that in the present instance, the diseased condition of the supra-
renal capsules did not result as usual from a deposit either of a
strumous or malignant character, but appears rather to have been
occasioned by an actual inflammation, — that inflammation hav-
ing destroyed the integrity of the organs, and finally led to their
contraction and atrophy.
Medical Classics
264
p. 22 CASE V
The following, taken from Dr. Bright’s Reports of medical
cases, presents, according to my belief, a very good illustration
of the disease under consideration, and is headed:
“Serous effusion under the arachnoid and into the ventricles
in a case of emaciation, with bilious vomiting and diseased renal
capsules.”
“ Ann Roots was admitted in July 1829, under one of the sur-
geons, into Guy’s Hospital, on account of a tumour in the left
breast and a swelling of the right parotid; but as it was perceived
that she was greatly emaciated and apparently sinking, and there-
fore quite unfit to undergo any operation, she was transferred to
the care of the physician.
“ Her complexion was very dark , her whole person emaciated;
she had no cough, and neither tension nor tenderness of abdomen;
she had great difficulty in opening her jaw, owing to the glandular
swelling, and could not protrude her tongue. There was no in-
dication but to support the strength. Her stomach soon became
irritable; she had bilious vomiting, which reduced her strength,
and for a day or two before her death, which took place on the
1 8th of August, she became drowsy, yet capable of being roused;
complaining of some pain over the forehead, and occasionally
wandering a little in her intellects.
“In the absence of all positive symptoms, I concluded that it
was possible some glandular disease, similar to that which had
shown itself below the mammae and under the jaw, might exist
internally, giving rise to emaciation and vomiting; and it ap-
peared probable that serous effusion had been going on in the
head for the last few days.
P- 2 3 " Sectio Cadaveris
Considerable emaciation; and on removing the integuments
the scalpel opened into an abscess, containing an ounce or two of
pus, situated beneath the mamma of the left side. The dura
mater was firmly attached to the skull at the vertex, where the
bone was remarkably thin, and indented by the glandule Pac-
Disease of Supra-Renal Capsules 265
chioni, and the ordinary opake deposit which surrounds them; on
raising the dura mater several small opacities were observable
on the arachnoid, and a very considerable quantity of serous
fluid was effused under the arachnoid, raising it into bladders, as
well as filling up the hollow between the convolutions.
“The whole brain was soft and watery, and many vessels
showed themselves where horizontal sections were made. In
the ventricles about half an ounce of fluid was collected. The
choroid plexus was quite exsanguine.
“Slight adhesions of the pleura pulmonalis and pleura costalis
were found, but not sufficient to prevent the lungs from collapsing
pretty completely when the air was admitted into the chest. The
upper lobe of each lung was in an unhealthy state, looking puck-
ered and containing one or two masses of earthy matter, besides
several small incipient tubercles; the greater part of the lungs,
however, was in a very healthy condition. Heart small, but
healthy. In the abdomen slight old adhesions had taken place
in various parts, but they were composed of the finest trans-
parent cellular tissue; even the omentum, which was glued by
them to various parts both of the intestines and the parietes,
had lost none of its natural delicacy and transparency. The
intestines were healthy, but stained with bile; the mucous mem-
brane healthy; the liver healthy, and the gall-bladder full of
bile; the pancreas healthy, and the spleen also, but just between
the pancreas and the spleen a few absorbent glands were en-
larged. The glands of the mesentery were also slightly enlarged.
The only marked disease was in the renal capsules, both of which
were enlarged, lobulated, and the seat of morbid deposits ap-
parently of a scrofulous character; they were at least four times
their natural thickness, (p. 24) feeling solid and hard; on the
left side one part had gone into suppuration, containing two
drachms of yellow pus. The kidneys themselves healthy. The
uterus held down by adhesions in the pelvis.”
It does not appear that Dr. Bright either entertained a sus-
picion of the disease of the capsules before death, or was led at
any period to associate the colour of the skin with the diseased
266 Medical Classics
condition of these organs, although his well-known sagacity in-
duced him to suggest the probable existence of some internal
malignant disease. In this, as in most other cases, we have the
same remarkable prostration; the usual gastric symptoms; the
same absence of any very obvious and adequate cause of the
patient’s actual condition, together with a discoloration of the
skin, sufficiently striking to have arrested Dr. Bright’s attention
even during the life of the patient.
p. 25 CASE VI
R. H., Esq., was a member of the bar, somewhere about middle
age. I had the satisfaction of attending him in consultation with
Dr. Watson and Mr. Barker, when I was informed that he had
been getting thin and emaciated during a period of about twelve
months. His appearance and symptoms were very remarkable.
He was certainly thin, but not strikingly emaciated, and the
surface was soft, loose and supple. He was greatly ansemiated;
his eyes were pearly; he complained of extreme languor and faint-
ness; his pulse, contrary to what is usual in capsular disease, was
of good size, but exquisitely soft and compressible; the impulse of
the heart was feeble, and palpitation or throbbing with scrobic-
ular pulsation was immediately produced by the slightest exer-
tion; without pain, the stomach was exceedingly irritable, and
vomiting was both urgent and distressing.
With these symptoms, the surface generally presented a dark
dingy aspect, and there were observed, chiefly on the face, neck
and arms, patches of a rather deep chestnut-brown colour; these
chestnut-brown patches were of various sizes and shapes, and
were associated here and there with others presenting a singularly
white or blanched appearance, arising either in consequence of
the latter portions of the integument having remained unaffected,
and so contrasting with the surrounding discoloration, or, what
is more probable, from their having received a less supply of pig-
ment than natural. A patient inquiry and most careful examina-
tion failed to elicit any information, or to detect any lesion, suffi-
cient to afford even a plausible explanation of the patient’s
singular condition. The violent vomiting pointed to organic.
Disease of Supra-Renal Capsules 267
perhaps carcinomatous disease of the stomach: nevertheless the
general condition and (p. 26) symptoms did not in other respects
seem to warrant such a conclusion; and coupling the existing
condition and symptoms with the irregular deposition of dark
pigment in the skin, a suspicion was entertained that the whole
might arise from disease of the supra-renal capsules. To the
last, however, considerable doubt prevailed amongst us as to the
true nature of the case, — chiefly in consequence of the severity
and persistence of the vomiting, and from the vomited mucous
matters having been occasionally tinged with blood. The patient
speedily sank, and the following report of the morbid appearances
discovered after death was furnished, I believe, by my distin-
quished friend Dr. Hodgkin,
“The morbid specimens consisted of part of the stomach and
duodenum, — the termination of the small, and the commence-
ment of the large intestines, with the appendix vermiformis, and
the renal capsules with a small portion of the kidney. They
were taken from a man rather beyond middle life, who for a con-
siderable time had suffered from obstinate derangement of the
stomach.
"The coats of the stomach taken unitedly did not produce any
preternatural thickness, but rather the reverse; yet there might
be a little thickening or increased development of the mucous
membrane. The peculiarity of its appearance consisted in a
spotted character not very easily described. Near the pylorus
it seemed to consist of a very slight degree of that irregularity
which Louis has described as the etat mamelonne , and which
appears to be nothing more than the increased development of a
natural structure; but in this instance the elevations were smaller
in size, and consequently more numerous, though less prominent
than those generally seen towards the middle of the stomach,
where this appearance is most frequently noticed.
“Further from the pylorus, in the direction of the smaller
curvature, smaller spots were seen more scattered and distant
from each other, and apparently consisting of opake lighter-
coloured matter, within the semi-transparent substance of the
268 Medical Classics
mucous membrane itself, which was generally (p. 27) of a faint
dusky reddish colour. It could not be decided whether these
spots depended on any glandular apparatus, yet the idea sug-
gested itself that they might be connected with the follicles of
Lieberkuhn. Immersion under water, with the intention of
facilitating the examination with the microscope, rendered these
spots less conspicuous. The largest might equal a small pin’s
head; the smaller ones scarcely a quarter so large. The duo-
denum appeared healthy. The portion of small and large in-
testine, of which the next specimen consisted, offered nothing
remarkable in texture. The mucous membrane was tinged with
the dingy olive-green of the faecal contents, and the ileo-colic
valve was rather more prominent than usual in the caecum. The
appendix vermiformis was about three inches in length, but much
distended, being about an inch in diameter at its commencement,
and becoming gradually less towards the free extremity, where it
but little exceeded the normal size. Its peritoneal coat was
quite healthy; its general thickness was very little increased;
its mucous membrane apparently healthy, of greyish colour,
from a little black pigment towards the upper part. Its follic-
ular apparatus was nearly or quite imperceptible. It was com-
pletely cut off from the interior of the intestine, the mucous mem-
brane forming a cul-de-sac at both extremities, although there
was no apparent want of continuity on the exterior; the septum
between the two cavities being merely composed of the two
mucous membranes united by cellular tissue. No appearance
of cicatrix was discovered, indicating that the separation was of
long standing, if not congenital. The contents of the appendix
consisted principally of a transparent colloid or thick mucoid
secretion, partly of a light straw colour, partly tinged with blood.
Interspersed through it, but especially towards the upper part,
was an opake white substance of the same consistence, resembling
coagulated milk or ground white lead. A few points were black-
ened by pigments. Examined with the microscope, the trans-
parent portion exhibited no determinate structure, but a slight
tendency to filamentous arrangement. The whole portion was
made up of a congeries of oil-globules, varying in size, but all
Disease of Supra-Renal Capsules 269
very minute. The (p. 28) black pigment appeared to pervade
some of the oil-globules, rather than itself to compose distinct
corpuscles. The basis of this collection was undoubtedly the
mucus of the appendix itself, retained by the want of any ex-
cretory passage.
“The small fragment of kidney appeared to be of healthy
structure, but both the renal capsules were enlarged, (the united
weight of the two being one and a half ounce,) of rather irregular
surface and considerably indurated. When cut into, instead of
exhibiting the ordinary appearance of combination of dark and
yellow substances, they seemed to consist of a firm, slightly trans-
parent reddish basis, interspersed with irregular spots of opake
yellow matter, the whole bearing a strong resemblance to an
enlarged mesenteric gland, mottled with tubercular deposit.
Such was probably the nature of the change which the organ had
undergone. The naked eye could discover no trace of cystiform
arrangement, and the opake matter when examined with the
microscope exhibited a copious amount of fatty matter, but no
nucleated cells.”
It was to me a matter of much regret that I had not an oppor-
tunity of employing an artist to make an exact representation of
the singular discoloration observed upon the skin, and the more
so, because, although agreeing in general character with those
observed in other cases, there was a manifest peculiarity, as well
in the intensity, as in the mode of distribution of these discolora-
tions. With universal dinginess of the surface, there were, es-
pecially about the neck, hands and arms, several well-defined
patches of a deeper, or somewhat chestnut-brown hue, inter-
spersed here and there with blanched or almost dead-white por-
tions of integument, contrasting in a very remarkable manner
with both the general dinginess and deeper brown patches; and
what is very remarkable, wherever the integument presented
the blanched or dead-white appearance, the hairs upon its surface
were observed to have turned completely white.
The superiority of a coloured drawing over the most elaborate
verbal (p. 29) description, in conveying a correct idea of any
2 jo Medical Classics
morbid appearance, is so universally felt and acknowledged, that
I have great satisfaction in being now able to furnish one, which
may most fairly and faithfully be applied to the above case.
Very recently — March 1855 — I was requested to visit a patient
(Mr. S.) about 60 years of age, who presented, in a strongly
marked degree, the indications of diseased renal capsules. The
history, mode of attack, the progress, the an semi a, the extreme
feebleness of the heart’s action, the uneasiness and irritability
of the stomach, and the discoloration of the skin, were all such
as characterize the disease generally, and bore the closest resem-
blance to the above case in particular. My belief was that the
capsules were affected with malignant disease, and that probably
some other structures about the posterior mediastinum might
have been in a similar condition, as the patient had slight oedema
of both the upper extremities, whilst the lower limbs remained
free. Anxious as I was to procure a post-mortem examination,
it was most firmly and peremptorily refused, and it was only
through the kind and persevering efforts of my friend, Mr.
Parrott of Clapham, that I succeeded in gaining permission'to
have a sketch taken of the discoloured integument. Of course
this representation does not carry along with it such authority
and conviction as one taken from a subject actually proved to
have had diseased capsules. Nevertheless I entertain no doubt
whatever that the capsules were diseased; and even if they were
not, I hold myself answerable for the most perfect resemblance
between the two cases, so far as the affection of the integument
was concerned. Vide PI. XI.
P- 3 ° case vn
The following case, having been under the care of one of the
surgeons for ‘carcinoma” of the mamma, I have not been able to
furnish any record of the symptoms during life. The corpse,
however, presented appearances sufficiently striking to arrest
the attention, and call forth the correct prediction of Dr. Lloyd
the inspector, who kindly furnished me with the following report.
Disease of Supra-Renal Capsules 271
“ Sectio Cadaveris
“ M . T., ast. 60. Cancerous disease of the mamma, with can-
cerous degeneration of the supra-renal capsules.
“Sixteen hours after death. Body extremely emaciated; the
left mamma presented a very extensive ulcerated phagedsenic
malignant tumour, occupying the whole of the upper part of the
left side of the chest, infiltrating the cellular tissue, the skin and
intercostal muscles with carcinomatous material. The colour of
the skin covering the face , arms and chest was of a peculiar light
brown swarthy hue.
"Chest. — On raising the sternum and cartilages, it was found
that the malignant growth had passed through the pleura and
invaded the lung on the left side, for a space of the size of the
palm of the hand, by direct continuity of structure. The pleural
cavity of the side contained about 16 oz. of dark-coloured fluid.
The lower lobe of the left lung was compressed, and sank in
water. The upper lobe was healthy. The right lung was healthy.
“ Heart — was small and flabby.
“ Abdomen . — The liver was contracted, irregular on its surface,
of yellow (p. 31) colour, containing abundance of fat, burning
brilliantly in the spirit-lamp; upon its surface were several nodules
of cancerous development. The gall-bladder was occupied in
its entire extent by a calculus, and did not contain any bile.
“Both supra-renal capsules contained a considerable amount
of cancerous deposit, invading their entire structure, and almost
obliterating their cavities.
“The kidneys were contracted and granular. The uterus
healthy, but atrophied.”
I have already expressed my belief that the urgency of the
symptoms, and the quick or slow progress of the disease, are
determined by the activity or rapidity of the morbid change
going on in the capsules, and by the actual amount or degree of
that change; and that universal disease of both capsules will in
all probability be found to prove uniformly fatal. These views
appear to be countenanced by the character, progress and ter-
mination of the cases already given, and receive additional con-
272
Medical Classics
firmation from the history of the following, in which the morbid
change was limited to a single capsule, and in which the constitu-
tional and local consequences indicated a corresponding result.
p. 32 CASE VIII. — REPORTED BY THE WARD CLERK
Elizabeth Hannah Lawrence , set. 53, admitted into Guy’s
Hospital under Dr. Babington, March 30, 1 853.
Appearance. — A short woman; emaciated and feeble; skin
harsh and dry, and of a darkish hue. The folds of the axillae were
remarkably dark: coloured patches, the size of the palm of the
hand, were observed, raised in wrinkles, and resembling a slight
Ichthyosis. Also a very dark brown areola around the umbilicus.
Hair grey; much long hair on lips and chin.
Previous History. — Is a single woman, has always been a serv-
ant, and has been living of late in Trinity Street, Borough. Was
always thin, but yet always enjoyed good health.
Present History. — Four months ago an eruption appeared on
her body, for the cure of which she went to the Cutaneous In-
firmary at Blackfriars. In a short time she was cured, and just
as the eruption disappeared, the present stomach symptoms be-
gan. For three months she has had vomiting, with pain in the
abdomen and back, particularly in the latter. She has thrown
up no blood. She was sent to the hospital as a case of malignant
disease of the stomach. The stomach can be felt as a hard tu-
mour in the abdomen: no remains of eruption on the skin. The
vomiting continued after admission, and in three days she died
from exhaustion.
Sectio Cadaver is
External Appe'arance. — The body that of a small emaciated
woman, with a fair skin and dark hair, presenting certain peculiar
discolorations. On (p. 33) either side of the neck there was a
tawny appearance, which would not have been remarked, had
it not been for three still more marked tawny patches, one on the
centre of the sternum, the other two under either axilla. The
skin also, besides presenting this yellowish-brown appearance,
was somewhat raised and wrinkled or corrugated. These marks
Disease of Supra-Renal Capsules 273
led me to prognosticate disease of the supra-renal capsules before
opening the body, believing them to be the marks pointed out by
Dr. Addison.
Thorax . — The lungs were congested, exuding a frothy serum,
and easily lacerable.
Heart . — Small and lacerable. The mediastinal glands in one
or two instances carcinomatous.
Abdomen . — Was shrunk and contracted.
Stomach . — The walls of the stomach from the pylorus through
the lesser curvature were thickened, presenting on the surface
externally a peculiar network appearance, containing a trans-
parent stroma; beneath this, another layer, with its fibres longi-
tudinally arranged, of strong cellular material; within this, the
mucous membrane whole and intact; the entire thickness being
about three-quarters of an inch at the pylorus, gradually de-
creasing to a quarter at the commencement of the cardia. The
mucous membrane lower down was here and there destroyed by
ulceration, and this ulceration in one instance of an eighth of an
inch in size. The stomach was contracted and empty; externally
to the stomach several of the glands were affected, even to the
head of the pancreas, but the pancreas itself was not affected.
Several of the lumbar glands were enlarged.
• The left supra-renal capsule was infiltrated with malignant
material, and closely adherent to the vessels of the kidney. The
kidney itself was healthy. The uterus contained three fibrous
tumours, the size of walnuts. Vide PI. VIII. fig. i, and Pis.
IX. and X.
Although this woman only survived four days after her ad-
mission into (p. 34) the hospital, we were led by the partial dis-
coloration of the skin to anticipate disease of the capsules, one
only of which, however, was found to be implicated. It will
have been perceived, that in a certain number of the cases al-
ready given, either strumous or malignant disease existed in
other parts or organs, as well as in the capsules; and of course, in
the midst of such complications, there is often more or less diffi-
culty in satisfactorily unravelling the case in all its details during
274 Medical Classics
life; nevertheless as we know, that without any such complication
whatever, mere disease of the capsules themselves has proved
sufficient to produce such alarming symptoms and such serious
consequences, it cannot with any show of reason be alleged that
these peculiar symptoms, when present, arise exclusively from
the accidental complication of other organs.
In the present instance, as in some others, the immediate cause
of death, as well as of many of the most distressing symptoms
during life, was unquestionably carcinomatous disease of thfe
stomach.
p. 35 CASE IX
'Thomas Clouston, set. 58, admitted into Guy’s Hospital, Febru-
ary 11, 185a, under Dr. Barlow. A muscular and strong-built
man, of a sanguine temperament and dark complexion. He has
been a married man, but his wife died about twenty years ago.
His occupation has been that of a sailor, and according to his
own statement, he has led a very sober life. His general health
has been very good. About five years since, he had a hernia in
the left inguinal region, for which he has since worn a truss.
This has never given him any difficulty to return. About two
months ago he came from Liverpool, in which place he had settled,
not intending to go to sea again; and was taken on board the
Dreadnought for stricture. His general health was quite good
at this time, but while in the Dreadnought he began to lose his
appetite and to feel generally unwell; he had likewise some affec-
tion of the left eye, in which he is now nearly blind.
On Saturday the 8 th he left the ship at his own request, think-
ing that he might be better on land; after waiting two or three
days, he found that he got no better, and his friends advised him
to come to the hospital.
Present Symptoms . — He complains of a sensation of sickness,
without actual vomiting; and tightness over the epigastrium.
His countenance is anxious. He has no pain in any part. He
has rigors, followed by mild sweats, every five or six hours, the
rigors usually lasting about an hour. The abdomen is tense and
tympanitic; not tender to the touch, excepting over the upper
Disease of Supra-Renal Capsules 275
part. The liver does not appear enlarged. His chest is broad
and well-formed; the motion of the ribs moderate, resonant on
percussion; and the lungs are apparently sound. The heart’s
sounds are normal. Pulse rather feeble, 80. Tongue injected
at the tip and edges, coated with a light brown fur, very dry.
Urine of about average (p. 36) quantity, rather large than other-
wise; of a high colour, acid, and does not coagulate by heat. The
bowels have been regular. After he had been in a few hours, he
brought up a large quantity of beer. Ordered
Mist. Efferves. 4tis horis.
Feb. 12. — The sickness has not returned, but he is without any
appetite. He slept but little.
Feb. 13. — He is much the same, but has a more sallow and
sunken expression of countenance. He complains of nothing but
loss of appetite and general debility. His tongue continues dry
and coated with a brownish fur. His bowels have been relaxed,
and he passed his motions partly involuntarily.
Feb. 14. — No special change.
Feb. 17. — He seems rather better; he had a little breakfast, and
enjoyed it.
Feb. 18. — He has relapsed into his former state, having no
appetite and complaining of great debility and thirst. He has
5iv of sherry daily.
Feb. 20. — There is but little change in him, bis countenance
appears to grow darker , and his strength seems gradually failing.
His bowels are rather irritable. Ordered
Enema Amyli c. Syr. Papav. g ss.
Inf. Cusparise giss t. d.
Feb. 25. — He has been getting gradually weaker, without show-
ing any special symptoms in addition to those mentioned. He
died this morning.
Sectio Cadaveris
None was allowed beyond the brain and abdomen; of the for-
mer there was considerable softening, and a large amount of
subarachnoid fluid. The kidneys were slightly enlarged, mottled.
Medical Classics
276
and in some parts the cortical substance was entirely degenerated
into fat. A few tubercles were observed on the surface. The
tunic was very easily taken from the surface. Tubercles were
also observed on the spleen, and on the (p. 37) peritoneum cover-
ing the termination of the Ileum. Tubercular deposit was like-
wise found in one of the supra-renal capsules. Vide Pis. VI.
VII.
The development of tubercles on various parts, as well as in
one of the supra-renal capsules, sufficiently attests the strumous
character of the patient’s disease; and it is difficult to divest one-
self of the notion that the disease in the supra-renal capsule had
some share in producing the peculiar symptoms which im-
mediately preceded the fatal result, whatever importance may
be attached to the state of the kidneys and cerebral complication.
At all events, the discoloration of the skin indicated before death
the existence of capsular disease; and it is worthy of remark,
that in this instance the deposition of pigment-cells was not
limited to the integument, but was found scattered in small
masses over the omentum, the mesentery, and the cellular tissue
on the interior of the abdominal parietes.
p. 38 case x
Ja 7 ie Roff, set. 28. This person was admitted into the Obstetric
Ward, labouring under cancer of the uterus, Feb. 4, 1852. She
died Feb. 8, and on the 9th the body was placed on the table for
inspection. When proceeding to perform this duty. Dr. Lloyd
was struck with the peculiar dingy appearance of the skin, and
in consequence, prior to commencing, sought me to look at it.
The appearance, though not very strongly marked, was certainly
such as to create a strong suspicion that something was wrong
with the capsules. On exposing the organ on the right side, it
presented a perfectly healthy appearance, and we felt disposed to
conclude that our anticipation would turn out to be erroneous.
On proceeding to examine the left capsule, however, we were
much surprised to find a very extraordinary, and, I suspect, an
extremely rare condition of parts. A malignant tubercle had
Disease of Supra-Renal Capsules 277
been developed at that precise point, where the large vein es-
capes from the organ; this tubercle projected into the interior
of the vein, so as almost or entirely to obstruct it, and had more-
over led to rupture and effusion into, or a sort of apoplexy of the
capsule itself.
This case would render it probable that the excess of dark pig-
ment, so characteristic of renal capsular disease, depended rather
upon an interruption to some special function, than upon the
nature of the organic change; for, with the exception of the mani-
festly recent sanguineous effusion into its tissue, the capsule itself
did not appear to have undergone any considerable deterioration.
Vide PI. VIII. figs, a, 3.
p. 39 CASE XI
I may observe in conclusion, that very recently there was ex-
amined at Guy’s Hospital the body of a person — William God-
frey — who had died of cancer, affecting the thoracic parietes, and
extending through to the lungs. Quite unexpectedly there was
found extensive disease of one of the supra-renal capsules; the
organ being very much enlarged, and converted into a hard mass
of apparently carcinomatous disease. On referring to the notes
of the case as taken by the clinical clerk, I found it stated
that ‘'the patient’s face presented a dingy hue ,” although he
was naturally of a fair complexion, with reddish or sandy hair on
the pubes; and, moreover, the face of the corpse was ascer-
tained to present a freckled and dingy appearance, with a slight
• brown discoloration at the root of the nose and at each angle of
the lips. Vide PI. VIII. figs. 6, 7, 8.
EXPLANATION OF THE PLATES
Plate I
Head of James Wooten. Both capsules diseased. Case I.
Plate II
Head of James Jackson. Both capsules diseased. Case II.
Plate III
Head of James Patten. Both capsules diseased. Case III.
Plate IV
Fig. i. The liver of Henry Patten, with the diseased supra-renal cap-
sules in situ .
Figs. 2 & 3. Sections of the diseased supra-renal capsules.
Plate V
Head and part of the trunk of John Iveson. Both capsules diseased.
Case IV.
Plate VI
Head of Thomas Clouston. A single capsule diseased. Case IX.
Plate VII
Separate parts from Thomas Clouston.
Fig. x. Portion of small intestine and mesentery with deposits of
dark pigment.
Fig. 2. Ditto.
Fig. 3. Portion of omentum with deposits of dark pigment.
Fig. 4. Deposit of dark pigment in the adipose tissue on the inner
surface of the internal oblique muscle.
Figs. 5 & 6. Microscopic views of the dark pigment taken from
fig. 1, (J inch).
Fig. 7. Natural size of the deposit represented in fig. 6.
Plate VIII
Fig. 1. The left kidney and diseased supra-renal capsule of Elizabeth
Lawrence. Case VIII.
Fig. 2. The left supra-renal capsule of Jane Roff, exhibiting a fungoid
growth obstructing the vein of the capsule at its entrance into
the renal vein. Case X.
-79
280 Medical Classics
Fig. 3 - Section of the same, exhibiting sanguineous infiltration of the
organ.
Fie- 4 * Section of one of the supra-renal capsules of James Jackson,
with strumous deposit. Case II.
Fig. 5 . Exterior view of the same.
Fie- 6 . Kidnev and diseased supra-renal capsule of W ilham Godfrey.
Case XI.
Fie- 7 . Microscopic view displaying meshes composed of a delicate
stroma of transparent and fibrous tissue, containing cancer cells,
taken from the diseased supra-renal capsule of William Godfrey.
Fig. 8 . Cancer juice, consisting of well formed cells, with large nuclei
and nucleoli, from the same.
Plate IX
X T eck and part of the trunk of Elizabeth Lawrence. A single capsule
diseased. Case VI 11.
Plate X
Abdomen of the same, exhibiting general dinginess of the integument,
with several small circumscribed deposits of darker pigment.
Plate XI
Head, neck and trunk of Mr. S., exhibiting peculiar discolorations and
white patches of the integument, similar to those observed in
Case VI.
MEDICAL CLASSICS
VOL. II
December, 1937
10 ®
NO. 4
CONTENTS
Portrait of William Withering ------ 294
William Withering
Biography - -- -- -- -- - 295
Eponyms - -- -- -- -- -- 296
Bibliography of Writings ------ 297
Bibliography of Biographies - - - - 299
An Account of the Foxglove, and Some of Its
Medical Uses, with Practical Remarks on
Dropsy, and Other Diseases. William
Withering ---------- - 305
WILLIAM WITHERING
MEDICAL CLASSICS
VOL. II
December, 1937
William Withering
NO. A
BIOGRAPHY
March 17, 1741. Bom at Wellington in Shropshire, England,
son of Edmund Withering, a physician, and of Sarah
Hector, his wife. Received a classical education from
a neighboring clergyman, the Reverend Henry Wood of
Ercall.
1762 Age ai. Entered the University of Edinburgh, studied
under Alexander Monro, primus, Joseph Black, Wil-
liam Cullen and Robert Whytt.
1766 Age 25. Graduated from Edinburgh with degree of
“Doctor of Physic,” his thesis being titled “Malignant
Putrid Sore Throat.” Traveled on the continent but
had an unhappy time because of the illness and death
of his companion. On returning home helped with his
father’s practice for a short time and then settled in
nearby Stafford. Appointed first physician of the newly
built Stafford Infirmary.
1767 Age 26. While practice was young and unhurried With-
ering gathered flowers to be painted by one of his
patients, Helena Cook. She became his wife.
1772 Age 31. Married. Began to look for a practice with a
larger income.
1775 Age 34. Moved to Birmingham where he was associated
with Dr. John Ash of the General Hospital. The in-
come of Stafford was doubled the first year in Birming-
ham.
=95
296 Medical Classics
1776 Age 35. Published his first book, “A botanical arrange-
ment of all the vegetables naturally growing in Great
Britain with descriptions of the genera and species ac-
cording to Linnaeus.” Continued studies on natural
history and had an increasingly busy practice. Joined
the Lunar Society of Birmingham, among its members
being James Watt, Josiah Wedgewood, Dr. Erasmus
Darwin and Joseph Priestley.
1783 Age 42. Had to give up practice for many months because
of poor health (pulmonary tuberculosis). Spent his
time in writing and translating; prepared manuscript
on digitalis.
1785 Age 44. Sought as consultant over a wide area of middle
and western England and Wales. In this year traveled
6,303 miles by horse and carriage to visit patients.
Published “An account of the fox-glove.” Elected a
Fellow of the Royal Society and given a diploma of
the Medical Society of London; both high honors.
Withering’s home at Edgbaston Hall was a mecca for
most of the distinguished scientists of the day.
1790 Age 49. Elected a Fellow of the Linnaean Society. Suf-
fered a serious attack of pleurisy.
1792 Age 51. Spent the winter in Portugal because of poor
health; returned there for the winter of 1793.
1:796 Age 55. Withering’s health forced him to retire.
1799 Age 58. Died on October 6 of pulmonary tuberculosis.
Buried in Edgbaston Church.
EPONYMS
Witherite: The natural barium carbonate, discovered by
Withering and named in his honor by the German geologist
Werner in ijgo. The mineral is found in large deposits in
crystalline form near Hexham, Northumberland, and is
used in the manufacturing of plate glass and paint and in
the refining of sugar.
Witherixgia: A genus of plants; term applied by the French
botanist, L’Heritier de Brutelle.
William Withering 297
BIBLIOGRAPHY OF WRITINGS
A — Army Medical Library.
B — New York Academy of Medicine Library.
C — Kings County Medical Society, Brooklyn, Library.
D — John Crerar Library, Chicago.
E — Lane Medical Library of Stamford University.
1. De angina gangraenosa. 31pp., 8° , Edinb., Auld & Smellie,
1766. In A and B.
2. Experiments upon the different kinds of marie found in
Staffordshire. Phil. Trans. Roy. Soc., Lond., 63: 161-162.
177 3 - '
3. A botanical arrangement of all the vegetables naturally
growing in Great Britain with descriptions of the genera
and species according to Linnaeus. 2 vols., 8°, 1776.
Botanical arrangement of British plants. 2 ed., 3 vols.,
8°, Birmingham, Robinson, 17S7-1792.
(Same) 3. ed., 4 vols., 8°, Birmingham, The author, 1796.
In B.
(Same) 4. ed., 4 vols., 8°, Lond., Cadell & Davies, 1S01.
In B.
(Same) 6. ed., corrected and considerably enlarged by
William Withering, Jr. 4 vols., 8°, Lond., Cadell &
Davies, 1818. In B and C.
4. Contributed scientific notes to John Talbot Dillon’s Travels
through Spain, with a view to illustrate the natural history
and physical geography of that kingdom, 1776.
5. An account of the scarlet fever and sore throat, or scarlatina
anginosa; particularly as it appeared at Birmingham in
the year 1778. 132 pp., 8°, Lond., 1779* A.
(Same) In German. Beschreibung des mit einem wehen
Hals verknupften Scharlachfiebers, sowic dasselbe besond-
ers im Jahre 1778 zu Birmingham in England erschien.
Aus dem Enelishcen ubersetzt und mit einigen Anmer-
kungen und Zusazen Yersehen von J. A. J. Sauer. 3 pi.,
136 pp., 12 0 , Frankfurt a. M., J. G. Garhc, 1781. In A.
(Same) 2. ed. To which are now prefixed some remarks
2g8 Medical Classics
on the nature and cure of the ulcerated sore throat. 127
pp., 8°, Birmingham, Robinson, 1793. In A, B, C, and E.
6. An analysis of two mineral substances, viz., the Rowley-
ragstone and the toad-stone. Phil. Trans. Roy. Soc.,
Lond., 72: 327-336, 1782.
7. Experiments and observations on the Terra pondorsa. Ibid.,
74:293-311, 1784.
8. An account of the fox-glove, and some of its medical uses;
with practical remarks on dropsy and other diseases,
xx, 207 pp., 1 p., 8°, Birmingham, Robinson, 1785. In
A, B and D.
(Same) In German. Abhandlung vom rothen Fingerhut
und dessen Anwendung in der praktischen Heilkunde
vorzeulich bei der Wassersucht und einigen andem Krank-
heiten. Aus dem Englischen vom — Christian Friedrich
Michaelis — Leipzig, In der Johann Gottfried Mullerschen
Buchhandlung, 1786. xxviii, 234 pp., I 1., 1 fold. col.
plate, 19.6 cm. In B and D.
(Same) In German. Bericht uber den Fingerhut und seine
medizinische Anwendung mit praktischen Bemerkungen
liber Wassersucht und andere Krankheiten. Nach der
englischen Ausgabe von 1785 ins Deutsche ubertragen.
209 pp., 1 pi., 8°, Mannheim, C. F. Boehringer & Soehne
G. m. b. H., 1929. In A.
9. Letter describing experience in effect of arsenic in the cure
of intermittents. In Thomas Fowler’s Medical Reports.
Lond., Johnson, 1786.
10. Letter to Joseph Priestley on acidity. Phil. Trans. Roy.
Soc., Lond., 78: 313-330, 1788.
11. An account of some extraordinary effects of lightning. Ibid.,
80: 293-295, 1790.
12. Letters from Dr. Withering. By Thomas Beddoes. (De-
scribes Withering’s views on tuberculosis). 8°, Bristol,
1794- In A.
13* Chemical analysis of the water at Caldas da Rainha. (In
Portuguese and English.) 8°, 1795.
14. The miscellaneous tracts of the late William Withering. To
William Withering 299
which is prefixed a memoir of his life, character and writ-
ings by the editor, W. Withering, Jr., with meteorological
and thcrmomctrical observations at Edgbaston, etc. 2
vols., vi, 496 pp., port., iv., 503 pp., 8°, London, Longman,
1822. In A and E.
BIBLIOGRAPHY OF BIOGRAPHIES
Biography by W. Withering, Jr. In Miscellaneous tracts of the
late William Withering. 8°, London, 1822, 1: 1-209.
Biography by G. S. Boulgcr. Diet. Nat. Biog., Lond., 62:
268-270, 1900.
William Withering and his book on the fox-glove. By Louis
Kolipinski. Med. Record, S6: 8-14, 1914.
Also: 22 pp., 1 1 ., 12 0 , N. Y., 1914.
Biography by A. R. Cushny. Proc. Roy. Soc. Med., Lond., S,
Sect. Hist. Med., S5-94, 1915.
William Withering. By Eli Moschcowitz. Med. Pickwick, i:
62-64, 1915.
Biography by G. M. Fay. Med. Press & Circ., Lond., 100: 39,
1915; 103: 208, 1917.
The pioneer in digitalis therapy and the prophet of intravenous
medication. Med. Times, N. Y., 46: 267, 1918.
Niederlandische Rcichsinstitutes fur pharmakotherapeutische
Untersuchungen. Die Digitalis, 1923.
Photographs of digitalis growing and of the tomb of William
Withering. By F. A. Smith. Minneapolis, 1925. 2 pi.
and letter in 4 0 envelope. In B.
Biography. Medical Life, 33: 424, 1926.
Biography by W. H. Wynn. Birmingham Med. Rev., n.s. 1:
45-63, 1926.
The Withering letters in the possession of The Royal Society of
Medicine. By Sir W. Hale-White. Proc. Roy. Soc. Med.
Lond., 22: Sect. Hist. Med., 37-41, 1928-29.
Letters and papers . . . presented to Yale University Library by
Mrs. Edward S. Harkness, edited by Isabel M. Calder. By
Ezra Stiles, x, 123 pp., 26 cm.. New Haven, Yale Univ.
Press, 1933. In B.
Medical Classics
3 °°
Withering on digitalis. By Wilfred T. Dawson and John Chap-
man. Ann. Med. Hist., 6: 31-34, 1934-
William Withering. The introduction of digitalis into medical
practice. By L. H. Roddis. Ann. Med. Hist., 8: 93-112
185-201, 1936.
Also, with additions, xi, 13 1 pp., 19.5 cm., N. Y., P. B.
Hoeber, 1936.
INTRODUCTION
William Withering published his book “An account of the fox-
glove” in 17S5. He tolls us in his own words, however, that his
attention was first drawn to the drug in 1775 when he was still in
practice in Stafford and before he had moved to the bigger field of
Birmingham. So we sec that the work for which William With-
ering is now famous was begun and practically completed while
he was a practitioner in a small town. He had settled in Stafford
nine years before, shortly after having been graduated from the
University of Edinburgh.
Withering wrote in the following manner:
“In the year 1775 my opinion was asked concerning a family
recipe for the cure of dropsy. I was told that it had long been
kept a secret by an old woman in Shropshire who had sometimes
made cures after the more regular practitioners had failed. I was
informed also that the effects produced were violent vomiting and
purging; for the diuretic effects seemed to have been overlooked.
This medicine was composed of twenty or more different herbs;
but it was not very difficult for one conversant in these subjects
to perceive that the active herb could be no other than foxglove.”
The foxglove was included in the 1783 edition of the Edinburgh
Pharmacopeia and its use quickly taken up by many doctors. As
with most newly described medicines, this drug was used indis-
criminately, in all types of diseases and in all manner of prepara-
tions and doses. A loud cry soon arose against this medicine.
Withering recognized its true worth and determined to be its
champion. He realized that if specific indications for digitalis
could be described, if definite preparations and doses could be
determined, the drug would have a very valuable place in medicine.
Withering expressed it thus:
“The use of the Foxglove is getting abroad and it is better the
world should derive some information, however imperfect, from
my experience, than that the lives of men should be hazarded by
its unguarded exhibition, or that a medicine of so much efficacy
should be condemned and rejected as dangerous and unmanage-
able.”
Here was the man who, having sufficient scientific training and
natural interest, seized upon the knowledge held by most of the
countryfolk around Stafford that foxglove was effective against
dropsy. Most of the old wives of that district had added fox-
glove to the concoctions of herbs which they used for dropsical
patients. Without great difficulty Withering determined that
the active principle was the foxglove. Just as Jenner brought
into the realm of science the countryman's knowledge of vaccina-
tion with cowpox against smallpox, so did Withering apply the
layman’s knowledge of the foxglove for dropsy.
The book which is here reproduced in its entirety is one of the
great classics of medicine. Copies are rarely found on the open
market and many of the largest medical libraries in the United
States do not own one. L. H. Roddis tells us that to his knowl-
edge the last one reported for sale appeared in 1932 for about
$262.50. To our knowledge the book has never been completely
reproduced.
The original volume contains only 207 pages. Preface and in-
troduction occupy pages v to xx. A beautiful plate is next inserted
which is approximately twelve by seventeen inches in size. With-
ering had had the natural colors of the Digitalis purpurea repro-
duced because he feared that his readers might mistake other
plants for the one he was describing. Pages 1 to 10 give an ac-
count of “The introduction of the foxglove into modern practice;”
pages 10 to 108 contain an account of patients who were treated
with digitalis. They represent many different types of disease
and the author carefully indicates the result of his treatment.
The remainder of the book is made up of the following important
headings: communications from correspondents, pages 109-178;
preparations and doses of the foxglove, 179-183; effects, rules and
cautions, 184-188; constitution of patients, 189-192; practical
remarks on dropsy, 193-207.
Withering sums up his knowledge of the use of digitalis in the
following words:
“Let it be continued until it acts either on the kidneys, the
stomach, the pulse, or the bowels; let it be stopped upon the first
appearance of any one of these effects, and I will maintain that
the patient will not suffer from its exhibition, nor the practitioner
be disappointed in any reasonable effects.”
We are deeply indebted to the Library of the New York Acad-
emy of Medicine for the use of their copy of Withering’s book in
the preparation of this volume.
A N
account
OF THE
foxglove,
AND
Some of its Medical Ufes :
\V I T It
PRACTICAL REMARKS ON DROPSY,
AND OTHER DISEASES.
B Y
WILLIAM WITHERING, M. D.
Phyfician to the General Hofpital at Birmingham.
nonumgue prematur in annum .
Horace,
BIRMINGHAM: PRINTED BY M.SWINNEY;
FOR
0. G. J. AND J. P.OBINSON, PATFUNOSTFR -Ro\V\ LONDON.
M,DCC,LXXXV.
An Account of the Foxglove, and
Some of Its Medical Uses; With
Practical Remarks on Dropsy,
and Other Diseases
BV
WILLIAM WITHERING, M.D.
Physician to the General Hospital at Birmingham
PREFACE
FTER being frequently urged to write upon this
subject, and as often declining to do it, from
apprehension of my own inability, I am at
length compelled to take up the pen, however
unqualified I may still feel myself for the
task.
The use of the Foxglove is getting abroad, and it is better the
world should derive some instruction, however imperfect, from
my experience, than that the lives of men should be hazarded by
its unguarded exhibition, or that a medicine of so much efficacy
should be condemned and rejected as dangerous and unmanage-
able.
(p. vi) It is now about ten years since I first began to use this
medicine. Experience and cautious attention gradually taught
me how to use it. For the last two years I have not had occasion
to alter the modes of management; but I am still far from think-
ing them perfect.
It would have been an easy task to have given select cases,
whose successful treatment would have spoken strongly in favour
Medical Classics
3°6
of the medicine, and perhaps been flattering to my own reputa-
tion. But Truth and Science would condemn the procedure. I
have therefore mentioned every case in which I have prescribed
the Foxglove, proper or improper, successful or otherwise. Such
a conduct will lay me open to the censure of those who are dis-
posed to censure, but it will meet the approbation of others, who
are the best qualified to be judges.
To the Surgeons and Apothecaries, with whom I am connected
in practice, both in this town and at a distance, I beg leave to
(p. vii) make this public acknowledgment, for the assistance
they so readily afforded me, in perfecting some of the cases, and
in communicating the events of others.
The ages of the patients are not always exact, nor would the
labour of making them so have been repaid by any useful con-
sequences. In a few instances accuracy in that respect was neces-
sary, and there it has been attempted; but in general, an approxi-
mation towards the truth, was supposed to be sufficient
The cases related from my own experience, are generally writ-
ten in the shortest form I could contrive, in order to save time
and labour. Some of them are given more in detail, when par-
ticular circumstances made such detail necessary; but the cases
communicated by other practitioners, are given in their own
words.
I must caution the reader, who is not a practitioner in physic,
that no general deductions, decisive upon the failure or success
(p. viii) of the medicine, can be drawn from the cases I now pre-
sent to him. These cases must be considered as the most hope-
less and deplorable that exist; for physicians are seldom consulted
in chronic diseases, till the usual remedies have failed: and, -in-
deed, for some years, whilst I was less expert in the management
of the Digitalis, I seldom prescribed it, but when the failure of
every other method compelled me to do it; so that upon the
whole, the instances I am going to adduce, may truly be con-
sidered as cases lost to the common run of practice, and only
snatched from destruction, by the efficacy of the Digitalis; and
this in so remarkable a manner, that, if the properties of that
plant had not been discovered, by far the greatest part of these
patients must have died.
The Foxglove 307
There are men who will hardly admit of any thing which an
author advances in support of a favorite medicine, and I allow
they may have some cause for their hesitation; nor do I expect
they will wave their usual modes of judging (p. ix) upon the pres-
ent occasion. I could wish therefore that such readers would
pass over what I have said, and attend only to the communica-
tions from correspondents, because they cannot be supposed
to possess any unjust predilection in favour of the medicine: but
I cannot advise them to this step, for I am certain they would
then close the book, with much higher notions of the efficacy of
the plant than what they would have learned from me. Not
that I want faith in the discernment or in the veracity of my
correspondents, for they are men of established reputation; but
the cases they have sent me are, with some exceptions, too much
selected. They are not upon this account less valuable in them-
selves, but they are not the proper premises from which to draw
permanent conclusions.
I wish the reader to keep in view, that it is not my intention
merely to introduce a new diuretic to his acquaintance, but one
which, though not infallible, I believe to be much more certain
than any other in present use.
(p. x) After all, in spite of opinion, prejudice, or error, Time
will fix the real value upon this discovery, and determine whether
I have imposed upon myself and others, or contributed to the
benefit of science and mankind.
Birmingham, 1st July, 1785.
(p. xi) INTRODUCTIONS
The Foxglove is a plant sufficiently common in this island, and
as we have but one species, and that so generally known, I should
have thought it superfluous either to figure or describe it; had I
not more than once seen the leaves of Mullein* gathered for those
of Foxglove. On the continent of Europe too, other species are
found, and I have been informed that our species is very rare in
some parts of Germany, existing only by means of cultivation in
gardens.
Verbascum of Linnaeus.
308 Medical Classics
Our plant is the Digitalis, purpurea* of Linnaeus. It belongs
to the 2d order of the 14th class, or the Didynamia Angiosper-
mia. The essential characters of the genus are, Cup with 5 divi-
sions. Blossom bell-shaped , bugling. Capsule egg-shaped , 2-
celled . — Linn.
Digitalis purpurea. Little leaves of the empalement egg-
shaped, sharp. Blossoms blunt; the upper lip entire. Linn.
(p. xii) References to Figures. These are disposed in the
order of comparative excellence.
Rivini monopet. 104.
Flora danica, 74, parts of fructification.
Foumefort Institutiones. 73, A , E, L, M.
Fuchsii Hist. Plant. 893, copied in
Fragi stirp. histor. 889.
J. Bauhini histor. Vol . ii. 812 , 3, and
Lonicera 74, 1.
Blackwell, auct. 16.
Dodonaei pempt. stirp. hist. 169, reprinted in
Gerard emacul. 790 , I, and copied in
Parkinson Fheatr. botanic. 63 1.
Gerard , first edition, 646 , 1.
Histor. Oxon. Morison. V. 8, row I. 1.
Flor. danic. 74, the reduced figure.
Blossom. The bellying part on the inside sprinkled with spots
like little eyes. Leaves wrinkled. Linn.
Blossom. Rather tubular than bell shaped, bulging on the
under side, purple; the narrow tubular part at the base, white.
Upper lip sometimes slightly cloven.
Chives. Threads crooked, white. Tips yellow.
Pointal. Seed-bud greenish. Honey-cup at its base more
yellow. Summit cloven,
S. Vess. Capsule not quite so long as the cup.
Root. Knotty and fibrous.
(p. xiii) Stem. About 4 feet high; obscurely angular; leafy.
The trivial name purpurea is not a very happy one, for the blossoms though generally
purple, are sometimes of a pure white.
The Foxglove 309
Leaves. Slightly but irregularly serrated, wrinkled; dark
green above, paler underneath. Lower leaves egg-shaped; upper
leaves spear-shaped. Leafstalks fleshy; bordered.
Flowers. Numerous, mostly growing from one side of the
stem and hanging down one over another. Floral-leaves fitting,
taper-pointed. The numerous purple blossoms hanging down,
mottled within; as wide and nearly half as long as the finger of a
common-sized glove, are sufficient marks whereby the most ig-
norant may distinguish this from every other British plant; and
the leaves ought not to be gathered for use but when the plant
is in blossom.
Place. Dry, gravelly or sandy soils; particularly on sloping
ground. It is a biennial, and flowers from the middle of June
to the end of July.
I have not observed that any of our cattle eat it. The root,
the stem, the leaves, and the flowers have a bitter herbaceous
taste, but I don’t perceive that nauseous bitter which has been
attributed to it.
This plant ranks amongst the Luridae, one of the Linnaean
orders in a natural system. It has for congenera, Nicotiana,
Atropa, Hyoscyamus, Datura, Solanum, & c. so that from the
knowledge we possess of the virtues of those plants, and reason-
ing from botanical analogy, we might be led to guess at something
of its properties.
(p. xiv) I intended in this place to have traced the history of
its effects in diseases from the time of Fuchsius, who first de-
scribes it, but I have been anticipated in this intention by my
very valuable friend. Dr. Stokes of Stourbridge, who has lately
sent me the following
HISTORICAL VIEW OF THE PROPERTIES OF DIGITALIS
Fuchsius in his hist, stirp. 1542, is the first author who notices
it. From him it receives its name of Digitalis, in allusion to the
German name of Fingerhut , which signifies a finger-stall,
from the blossoms resembling the finger of a glove.
Sensible Qualities. Leaves bitterish, very nauseous.
Lewis Mat. med. i. 342.
310 Medical Classics
Sensible Effects. Some persons, soon after eating of a
land of omalade, into which the leaves of this, with those of
several other plants, had entered as an ingredient, found them-
selves much indisposed, and were presently after attacked with
vomitings. Dodonaeus pempt . 170.
It is a medicine which is proper only for strong constitutions,
as it purges very violently, and excites excessive vomitings.
Ray. hist. 767.
Boerhaave judges it to be of a poisonous nature, hist, plant.
but Dr. Alston ranks it among those indigenous vegetables,
■“which, though now disregarded, (p. xv) are medicines of great
virtue, and scarcely inferior to any that the Indies afford.”
Lewis. Mat. med. i. p. 343.
Six or seven spoonfuls of the decoction produce nausea and
vomiting, and purge; not without some marks of a deleterious
quality. Haller hist. n. 330 from Aerial Inst. p. pp, 30.
THE FOLLOWING IS AX ABRIDGED ACCOUNT OF ITS EFFECTS
UPON TURKEYS
M. Salerne, a physician at Orleans, having heard that several
turkey pouts had been killed by being fed with Foxglove leaves,
instead of mullein, he gave some of the same leaves to a large
vigorous turkey. The bird was so much affected that he could
not stand upon his legs, he appeared drunk, and his excrements
became reddish. Good nourishment restored him to health in
eight days.
Being then determined to push the experiment further, he
chopped some more leaves, mixed them with bran, and gave them
to a vigorous turkey cock which weighed seven pounds. This
bird soon appeared drooping and melancholy; his feathers stared,
his neck became pale and retracted. The leaves were given him
for four days, during which time he took about half a handful.
These leaves had been gathered about eight days, and the winter
was far advanced. The excrements, which are naturally (p. xvi)
green and well formed, became, from the first, liquid and reddish,
like those of a dysenteric patient.
The animal refusing to eat any more of this mixture which
The Foxglove 311
had done him so much mischief, I was obliged to feed him with
bran and water only; but notwithstanding this, he continued
drooping, and without appetite. At times he was seized with
convulsions, so strong as to throw him down; in the intervals
he walked as if drunk; he did not attempt to perch, he uttered
plaintive cries. At length he refused all nourishment. On the
fifth or sixth day the excrements became as white as chalk;
afterwards yellow, greenish, and black. On the eighteenth day
he died, greatly reduced in flesh, for he now weighed only three
pounds.
On opening him we found the heart, the lungs, the liver, and
. gall-bladder shrunk and dried up; the stomach was quite empty,
but not deprived of its villous coat. Hist, de VAcadem. 1748.
p. 84.
Epilepsy. — “It hath beene of later experience found also to
be effectual against the falling sickness, that divers have been
cured thereby; for after taking of the Decoct, manipulor. it. c.
polypod. quercw. contus. oz. iv. in cerevisia, they that have been
troubled with it twenty-six years, and have fallen once in a weeke,
or two or three times in a moneth, have not fallen once in four-
teen or fifteen moneths, that is until the writing hereof.” Park-
kittson , p. 654.
(p. xvii) Scrophula. — “The herb bruised, or the juice made up
into an ointment, and applied to the place, hath been found by
late experience to be availeable for the King’s Evill.” Park.
P- 654.
Several hereditary instances of this disease said to have been
cured by it. Aereal Influences, p. 49, 50, quoted by Haller,
hist. n. 330.
A man with scrophulous ulcers in various parts of the body,
and which in the right leg were so virulent that its amputation
was proposed, cured by fttcc. express, cochl. i. his intra xiv. dies ,
in f pinta cerevisiae calidae.
The leaves remaining after the pressing out of the juice, were
applied every day to the ulcers. Pract. ess. p. 40 quoted by
Murray apparat. medicam. i. p. 491.
A young woman with a scrophulous tumour of the eye, a re-
Medical Classics
3 12
markable swelling of the upper lip, and painful tumours of the joints
of the fingers, much relieved; but the medicine was left off, on
account of its violent effects on the constitution. Ib. p. 42
quoted as above.
A man with a scrophulous tumour of the right elbow , attended
for three years with excruciating pains, was nearly cured by four
doses of the juice taken once a month. Ib. p. 43. as above.
The physicians and surgeons of the Worcester Infirmary have
employed it in ointments and poultices with remarkable efficacy.
Ib. p. 44. It was recommended (p. xviii) to them by Dr. Bay lies
of Evesham, now of Berlin, as a remedy for this disease. Dr.
Wall gave it a tryal, as well externally as internally, but their
experiments did not lead them to observe any other properties
in it, than those of a highly nauseating medicine and drastic
purgative.
Wounds. In considerable estimation for the healing all kinds
of wounds, Lobel. ado. 243.
Principally of use in ulcers, which discharge considerably,
being of little advantage in such as are dry. Hulse, in R. hist.
768.
Doctor Baylies, physician to his Prussian Majesty, informed
me, when at Berlin, that he employed it with great success in
caries, and obstinate sore legs.
Dyspnoea Pituitosa Sauvages i. 657. — “Boiled in water or
wine, and drunken doth cut and consume the thicke toughnesse
of grosse, and slimie flegme, and naughtie humours. The same,
or boiled with honied water or sugar, doth scoure and dense the
brest, ripeneth and bringeth foorth tough and clammie flegme.
It openeth also the stoppage of the liver spleene and milt, and
of the inwarde parts.” Gerarde hist. ed. 1 . p. 647.
Whensoever there is need of a rarefying or extenuating of tough
flegme or viscous humours troubling the chest, — the decoction
or juice hereof made up with sugar or honey is availeable, as also
to dense and purge the body both upwards (p. xix) and down-
wards sometimes, of tough flegme, and clammy humours, not-
withstanding that these qualities are found to bee in it, there
are but few physitions in our times that put it to these uses,
but it is in a manner wholly neglected,” Parkinson, p. 65 4.
The Foxglove 313
Previous to the year 1777, you informed me of the great suc-
cess you had met with in curing dropsies by means of the fol.
Digitalis, which you then considered as a more certain diuretic
than any you had ever tried. Some time afterwards, Mr. Russel,
surgeon, of Worcester, having heard of the success which had
attended some cases in which you had given it, requested me to
obtain for him any information you might be inclined to com-
municate respecting its use. In consequence of this application,
you wrote to me in the following terms.*
In a letter which I received from you in London, dated Septem-
ber 29, 1778, you write as follows: — “I wish it was as easy to write
upon the Digitals — I despair of pleasing myself or instructing
others, in a subject so difficult. It is much easier to write upon a
disease than upon a remedy. The former is in the hands of
nature, and a faithful observer, with an eye of tolerable judgment,
cannot fail to delineate a likeness. The latter will ever be sub-
ject to the whims, the inaccuracies, and the blunders of man-
kind.”—
(p. xx) In my notes I find the following memorandum — “ Feb-
ruary 20th, 1779, gave an account of Doctor Withering’s prac-
tice, with the precautions necessary to its success, to the Medical
Society at Edinburgh.” — In the course of that year, the Digitalis
was prescribed in the Edinburgh Infirmary, by Dr. Hope, and
in the following year, whilst I was Clerk to Dr. Home, as Clinical
Professor, I had a favourable opportunity of observing its sen-
sible effects.
In one case in which it was given properly at first, the urine
began to flow freely on the second day. On the third, the
swellings began to subside. The dose was then increased more
than quadruple in the twenty-four hours. On the fifth day
sickness came on, and much purging, but the urine still increased
though the pulse sunk to 50. On the 7th day, a quadruple
dose of the infusion was ordered to be taken every third hour, so
as to bring on nausea again. The pulse fell to forty-four, and at
length to thirty-five in a minute. The patient gradually sunk
and died on the sixteenth day; but previous to her death, for
two or three days, her pulse rose to near one hundred. — It is
* See the extract from this letter at page 5.
314 Medical Classics
needless to observe to you, how widely the treatment of this
case differed from the method which you have found so suc-
cessful.
OF THE PLATE
The figure of the Foxglove, facing the Title Page, is copied by
the permission and under the inspection of Mr. Curtis, from his
admirable work, entitled Flora Londinensis. The accuracy
of the drawings, the beauty of the colouring, the full descrip-
tions, the accurate specific distinctions, and the uses of the differ-
ent plants, cannot fail to recommend that work to the patronage
of all who are interested in the encouragement of genius, or the
promotion of useful knowledge.
Explanation
Fig. 1. The Empalement.
Fig. 2, 3, 4. Four Chives two long and two short, Tips at first
large, turgid, oval, touching at bottom, of a yellowish
colour, and often spotted; lastly changing both their form
and situation in a singular manner.
Fig- 5> 6, 7. Seed-bud rather conical, of a yellow green colour.
Shaft simple. Summit cloven.
Fig. 8. Honeycup a gland, surrounding the bottom of the Seed-
bud.
Fig. 9. Seed-vessel, a pointed oval capsule , of two cells and two
valves, the lowermost valve splitting in two.
Fig. 10. Seeds numerous, blackish, small, lopped at each end.
AN ACCOUNT OF THE INTRODUCTION OF FOXGLOVE INTO
MODERN PRACTICE
As the more obvious and sensible properties of plants, such
as colour, taste, and smell, have but little connexion with the
diseases they are adapted to cure; so their peculiar qualities have
no certain dependence upon their external configuration. Their
chemical examination by fire, after an immense waste of time and
labour, having been found useless, is now abandoned by general
consent. Possibly other modes of analysis will be found out,
The Foxglove 315
which may turn to better account; but we have hitherto made
only a very small progress in the chemistry of animal and vege-
table substances. Their virtues must therefore be learnt, either
from observing their effects upon insects and quadrupeds; from
analogy, deduced from the already known powers of some of
their congenera, or from the empirical usages and experience of
the populace.
The first method has not yet been much attended to; and the
second can only be perfected in proportion as we approach to-
wards the discovery of a truly natural system; but the last, as
far as it extends, lies (p. 1 ) within the reach of every one who is
open to information, regardless of the source from whence it
springs.
It was a circumstance of this kind which first fixed my atten-
tion on the Foxglove.
In the year 1775, m y opinion was asked concerning a family
receipt for the cure of the dropsy. I was told that it had long
been kept a secret by an old woman in Shropshire, who had some-
times made cures after the more regular practitioners had failed.
I was informed also, that the effects produced were violent vom-
iting and purging; for the diuretic effects seemed to have been
overlooked. This medicine was composed of twenty or more
different herbs; but it was not very difficult for one conversant
in these subjects, to perceive, that the active herb could be no
other than the Foxglove.
My worthy predecessor in this place, the very humane and
ingenious Dr. Small, had made it a practice to give his advice
to the poor during one hour in a day. This practice, which I
continued until we had an Hospital opened for the reception of
the sick poor, gave me an opportunity of putting my ideas into
execution in a variety of cases; for the number of poor who thus
applied for advice, amounted to between two and three thousand
annually. I soon found the Foxglove to be a very powerful
diuretic; but then, and for a considerable time afterwards, I
gave it in doses very much too (p. 3) large, and urged its con-
tinuance too long; for misled by reasoning from the effects of
the squill, which generally acts best upon the kidneys when it
Medical Classics
316
excites nausea, I wished to produce the same effect by the Fox-
glove. In this mode of prescribing, when I had so many patients
to attend to in the space of one, or at most of two hours, it will
not be expected that I could be very particular, much less could
I take notes of all the cases which occurred. Two or three of
them only, in which the medicine succeeded, I find mentioned
amongst my papers. It was from this kind of experience that
I ventured to assert, in the Botanical Arrangement published
in the course of the following spring, that the Digitalis purpurea
“merited more attention than modern practice bestowed upon
it.”
I had not, however, yet introduced it into the more regular
mode of prescription; but a circumstance happened which
accelerated that event. My truly valuable and respectable
friend. Dr. Ash, informed me that Dr. Cawley, then principal
of Brazen Nose College, Oxford, had been cured of a Hydrops
Pectoris, by an empirical exhibition of the root of the Foxglove,
after some of the first physicians of the age had declared they
could do no more for him. I was now determined to pursue my
former ideas more vigorously than before, but was too well
aware of the uncertainty which must attend on the exhibition
of the root of a biennial plant, and therefore continued to use the
leaves. These I had found to vary much as to dose, at different
seasons of the year; (p. 4) but I expected, if gathered always in
one condition of the plant, viz. when it was in its flowering state,
and carefully dried, that the dose might be ascertained as exactly
as that of any other medicine; or have I been disappointed in
this expectation. The more I saw of the great powers of this
plant, the more it seemed necessary to bring the doses of it to
the greatest possible accuracy. I suspected that this degree
of accuracy was not reconcileable with the use of a decoction^ as
it depended not only upon the care of those who had the prepara-
tion of it, but it was easy to conceive from the analogy of another
plant of the same natural order, the tobacco, that its active prop-
erties might be impaired by long boiling. The decoction was
therefore discarded, and the infusion substituted in its place.
After this I began to use the leaves in poivder, but I still very often
prescribe the infusion.
The Foxglove 317
Further experience convinced me, that the diuretic effects
of this medicine do not at all depend upon its exciting a nausea
or vomiting; but, on the contrary, that though the increased
secretion of urine will frequently succeed to, or exist along with
these circumstances, yet they are so far from being friendly
or necessary, that I have often known the discharge of urine
checked, when the doses have been imprudently urged so as to
occasion sickness.
If the medicine purges, it is almost certain to fail in its desired
effect; but this having been the case, I have seen it afterwards
succeed when joined with (p. 5) small doses of opium, so as to
refrain its action on the bowels.
In the summer of the year 1776, I ordered a quantity of the
leaves to be dried, and as it then became possible to ascertain
the doses, it was gradually adopted by the medical practitioners
in the circle of my acquaintance.
In the month of November 1777, in consequence of an applica-
tion from that very celebrated surgeon, Mr. Russel, of Worces-
ter, I sent him the following account, which I choose to introduce
here, as shewing the ideas I then entertained of the medicine,
and how much I was mistaken as to its real dose. —
“I generally order it in decoction. Three drams of the dried
leaves, collected at the time of the blossoms expanding, boiled
in twelve to eight ounces of water. Two spoonfuls of this medi-
cine, given every two hours, will sooner or later excite a nausea.
I have sometimes used the green leaves gathered in winter, but
then I order three times the weight; and in one instance I used
three ounces to a pint decoction, before the desired effect took
place. I consider the Foxglove thus given, as the most certain
diuretic I know, nor do its diuretic effects depend merely upon
the nausea it produces, for in cases where squill and ipecac have
been so given as to keep up a nausea several days together, and
the flow of urine not taken place, I have found the Foxglove to
succeed; and I have, in more than one instance, given the Fox-
glove in smaller and (p. 6) more distant doses, so that the flow
of urine has taken place without any sensible affection of the
stomach; but in general I give it in the manner first mentioned,
and order one dose to be taken after the sickness commences, I
Medical Classics
3 1 ^
then omit all medicines, except those of the cordial kind are
wanted, during the space of three, four, or five days. By this
time the nausea abates, and the appetite becomes better than it
was before. Sometimes the brain is considerably affected by the
medicine, and indistinct vision ensues, but I have never yet found
any permanent bad effects from it.
“I use it in the Ascites, Anasarca, and Hydrops Pectoris; and
so far as the removal of the water will contribute to cure the
patient, so far may be expected from this medicine: but I wish
it not to be tried in ascites of female patients, believing that many
of these cases are dropsies of the ovaria; and no sensible man will
ever expect to see these encysted fluids removed by any medicine.
“I have often been obliged to evacuate the water repeatedly
in the same patient, by repeating the decoction; but then this
has been at such distances of time as to allow of the interference
of other medicines and a proper regimen, so that the patient ob-
tains in the end a perfect cure. In these cases the decoction be-
comes at length so very disagreeable, that a much smaller
quantity will produce the effect, and I often find it necessary to
alter its taste by the addition of Aq. Cinnam. sp. or Aq. Juniper,
composita.”
(p. 7) “I allow, and indeed enjoin my patients to drink very
plentifully of small liquors through the "whole course of the cure;
and sometimes, where the evacuations have been very sudden,
I have found a bandage as necessary as in the use of the tro-
char.”—
Early in the year 1779, a number of dropsical cases offered
themselves to my attention, the consequences of the scarlet
fever and sore throat which had raged so very generally amongst
us in the preceding year. Some of these had been cured by squills
or other diuretics, and relapsed; in others, the dropsy did not
appear for several weeks after the original disease had ceased:
but I am not able ,to mention many particulars, having omitted
to make notes. This, however, is the less to be regretted, as the
symptoms in all were very much alike, and they were all without
exception cured by the Foxglove.
This last circumstance encouraged me to use the medicine more
The Foxglove 319
frequently than I had done heretofore, and the increase of prac-
tice had taught me to improve the management of it.
In February 1779, my friend, Dr. Stokes, communicated to
the Medical Society at Edinburgh the result of my experience
of the Foxglove; and, in a letter addressed to me in November
he says, “Dr. Hope, in consequence of my mentioning its use to
my friend, Dr. Broughton, has tried the Foxglove in the Infir-
mary with success.” Dr. (p. 8) Stokes also tells me that Dr.
Hamilton cured Dropsies with it in the year 1781.
I am informed by my very worthy friend Dr. Duncan, that
Dr. Hamilton, who learnt its use from Dr. Hope, has employed
it very frequently in the Hospital at Edinburgh. Dr. Duncan
also tells me, that the late very ingenious and accomplished Mr.
Charles Darwin, informed him of its being used by his father and
myself, in cases of Hydrothorax, and that he has ever since men-
tioned it in his lectures, and sometimes employed it in his practice.
At length, in the year 1783, it appeared in the new edition of
the Edinburgh Pharmacopoeia, into which, I am told, it was
received in consequence of the recommendation of Dr. Hoppe.
But from which, I am satisfied, it will be again very soon rejected,
if it should continue to be exhibited in the unrestrained manner
in which it has heretofore been used at Edinburgh, and in the
enormous doses in which it is now directed in London.
In the following cases the reader will find other diseases be-
sides dropsies; particularly several cases of consumption. I
was induced to try it in these, from being told, that it was much
used in the West of England, in the Phthisis Pulmonalis, by the
common people. In this disease, however, in my hands, it has
done but little service, and yet I am disposed to wish it a further
trial, for in a copy of Parkinson’s Herbal, which I saw about two
years ago, (p. 9) I found the following manuscript note at the
article Digitalis, written, I believe, by a Mr. Saunders, who prac-
ticed for many years with great reputation as a surgeon and
apothecary at Stourbridge, in Worcestershire.
“Consumptions are cured infallibly by weak decoction of
Foxglove leaves in water, or wine and water, and drank for con-
stant drink. Or take of the juice of the herb and flowers, clarify
Medical Classics
3 2 °
it, and make a fine syrup with honey, of which take three spoon-
fuls thrice in a day, at physical hours. The use of these two
things of late has done, in consumptive cases, great wonders.
But be cautious of its use, for it is of a vomiting nature. In
these things begin sparingly, and increase the dose as the pa-
tient’s strength will bear, least, instead of a sovereign medicine,
you do real damage by this infusion or syrup.”
The precautions annexed to his encomiums of this medicine,
lead one to think that he has spoken from his own proper experi-
ence.
I have lately been told, that a person in the neighbourhood of
Warwick, possesses a famous family receipt for the dropsy, in
which the Foxglove is the active medicine; and a lady from the
western part of Yorkshire assures me, that the people in her coun-
try often cure themselves of dropsical complaints by drinking
Foxglove tea. In confirmation of this, I recollect about two
}>ears ago being desired to visit a (p. io) travelling Yorkshire
tradesman. I found him incessantly vomiting, his vision in-
distinct, his pulse forty in a minute. Upon enquiry it came out,
that his wife had stewed a large handful of green Foxglove leaves
in half a pint of water, and given him the liquor, which he drank
at one draught, in order to cure him of an asthmatic affection.
This good 'woman knew the medicine of her country, but not the
dose of it, for her husband narrowly escaped with his life.
It is probable that this rude mode of exhibiting the Foxglove
has been more general than I am at present aware of; but it is
wonderful that no author seems to have been acquainted with
its effects as a diuretic.
CASES IN WHICH THE DIGITALIS WAS GIVEN BY THE DIRECTION
OF THE AUTHOR
*77S
It was in the course of this year that I began to use the Digitals
in dropsical cases. The patients were such as applied at my
house for advice gratis. I cannot pretend to charge my memory
with particular cases, or particular effects, and I had not leisure
The Foxglove 321
to make notes. Upon the whole, however, it may be concluded,
that the medicine was found useful, or I should not have contin-
ued to employ it.
Case I
December 8th. A man about fifty years of age, who had for-
merly been a builder, but was now much reduced in his circum-
stances, complained to me of an asthma which first attacked him
about the latter end of autumn. His breath was very short,
his countenance was sunken, his belly large; and, upon examina-
tion, a fluctuation in it was very perceptible. His urine for some
time past had been small in quantity. I directed a decoction of
Fol. Digital, recent, which made him very sick, the sickness
recurring at intervals for several days, during which time he made
a large quantity of water. His breath gradually drew easier, his
belly subsided, and in (p. ia) about ten days he began to eat with
a keen appetite. He afterwards took steel and bitters.
1776
Case II
January 14th. A poor man labouring under an ascites and
anasarca, was directed to take a decoction of Digitalis every
four hours. It purged him smartly, but did not relieve him.
An opiate was now ordered with each dose of the medicine, which
then acted upon the kidneys very freely, and he soon lost all his
complaints.
Case III
March 15th. A poor boy, about nine years of age, was brought
for my advice. His countenance was pale, his pulse quick and
feeble, his body greatly emaciated, except his belly, which was
very large, and, upon examination, contained a fluid. The case
had been considered as arising from worms. He was directed to
take the decoction of Digitalis night and morning. It operated
as a diuretic, never made him sick, and he got well without any
other medicine.
322 Medical Classics
Case IV
July 15th. Mrs. H , of A , near N , between forty
and fifty years of age, a few weeks ago, after some previous in-
disposition, was attacked by a severe cold shivering fit, succeeded
by fever; great pain in her left side, shortness of breath, perpetual
cough, and, after some days, (p. 13) copious expectoration. On
the 4th of June , Dr. Darwin,* was called to her. I have not
heard what was then done for her, but between the 15th of
June, and 25th of July, the Doctor, at his different visits, gave
her various medicines of the deobstruent, tonic, antispasmodic,
diuretic, and evacuant kinds.
On the 25th of July I was desired to meet Dr. Darwin at the
lady’s house. I found her nearly in a state of suffocation; her
pulse extremely weak and irregular, her breath very short and
laborious,- her countenance sunk, her arms of a leaden colour,
clammy and cold. She could not lye down in bed, and had nei-
ther strength nor appetite, but was extremely thirsty. Her
stomach, legs, and thighs were greatly swollen; her urine very
small in quantity, not more than a spoonful at a time, and that
very seldom. It had been proposed to scarify her legs, but the
proposition was not acceded to.
She had experienced no relief from any means that had been
used, except from ipecacoanha vomits; the dose of which had
been gradually increased from 15 to 40 grains, but such was the
insensible state of her stomach for the last few days, that even
those very large doses failed to make her sick, and consequently
purged her. In this situation of things I knew of nothing likely
to avail us, except the Digitalis: but this I hesitated to propose,
from an apprehension that little could be expected from any
thing; that an unfavourable termination would tend to (p. 14)
discredit a medicine which promised to be of great benefit to
mankind, and I might be censured for a prescription which could
not be countenanced by the experience of any other regular
practitioner. But these considerations soon gave way to the
desire of preserving the life of this valuable woman, and accord-
*Then resident at Lichfield, now at Derby.
The Foxglove 323
ingly I proposed the Digitalis to be tried; adding, that I some-
times had found it to succeed when other, even the most judicious
methods, had failed. Dr. Darwin very politely, acceded im-
mediately to my proposition and, as he had never seen it given,
left the preparation and the dose to my direction. We therefore
prescribed as follows:
R. Fol. Digital, purp. recent, oz. iv. coque ex Aq. fontan.
purae lb iss ad lb i. et cola.
R. Decoct. Digital, oz. iss.
Aq. Nuc. Moschat. oz. ii. M. fiat, haust. 2dis horis
sumend.
The patient took five of these draughts, which made her very
sick, and acted very powerfully upon the kidneys, for within the
first twenty-four hours she made upwards of eight quarts of
water. The sense of fulness and oppression across her stomach
was greatly diminished, her breath was eased, her pulse became
more full and regular, and the swellings of her legs subsided.
26th. Our patient being thus snatched from impending de-
struction, Dr. Darwin proposed to give her a decoction of pareira
brava and guiacum shavings, (p. 15) with pills of myrrh and white
vitriol; and, if costive, a pill with calomel and aloes. To these
propositions I gave a ready assent.
30th. This day Dr. Danvin saw her, and directed a continua-
tion of the medicines last prescribed.
August 1 st. I found the patient perfectly free from every
appearance of dropsy, her breath quite easy, her appetite much
improved, but still very weak. Having some suspicion of a dis-
eased liver, I directed pills of soap, rhubarb, tartar of vitriol, and
calomel to be taken twice a day, with a neutral saline draught.
9th. We visited our patient together, and repeated the
draughts directed on the 26th of June, with the addition of
tincture of bark, and also ordering pills of aloes, guiacum, and
sal martis to be taken if costive.
September 10th. From this time the management of the case
fell entirely under my direction, and perceiving symptoms of
effusion going forwards, I desired that a solution of mere. subl.
corr. might be given twice a day.
g 24 Medical Classics
19th. The increase of the dropsical symptoms now made it
necessary to repeat the Digitalis. The dried leaves were used
in infusion, and the water was presently evacuated, as before.
(p. 16) It is now almost nine years since the Digitalis was first
prescribed for this lady, and notwithstanding I have tried every
preventive method I could devise, the dropsy still continues to
recur at times; but is never alowed to increase so as to cause much
distress, for she occasionally takes the infusion and relieves her-
self whenever she chooses. Since the first exhibition of that
medicine, very small doses have been always found sufficient to
promote the flow of urine.
I have been more particular in the narrative of this case, partly
because Dr. Darwin has related it rather imperfectly in the notes
to his son’s posthumous publication, trusting, I imagine, to
memory, and partly because it was a case which gave rise to a
very general use of the medicine in that part of Shropshire.
Case V
December 10th. Mr. L , Aet, 35. Ascites and anasarca,
the consequence of very intemperate living. After trying squill
and other medicines to no purpose, I directed a decoction of the
Fol. Digital, recent, six drams to a pint; an eighth part to be
taken every fourth hour. This made him sick, and produced a
copious flow of urine, but not enough to remove all the dropsical
symptoms. After a fortnight a stronger decoction was ordered,
and upon a third trial, as the winter advanced, it became neces-
sary to use four ounces to the pint decoction; and thus he got
free from all his complaints.
(p- 17) In October 1777, in consequence of having pursued his
intemperate mode of living, his dropsy returned, accompanied
by evident marks of diseased viscera. A decoction of two drams
of Fol. Digital, siccat. to a pint, once more removed the dropsy.
He took a wine glass full thrice a day.
In January 1778, 1 was desired to visit him again. I found he
had gone on in his usual intemperate life, his countenance jaun-
diced, and the dropsy coming on apace. After giving some de-
obstruent medicines, I again directed the Digitalis, which again
emptied the water; but he did not survive many weeks.
The Foxglove 325
1777
Case VI
February — . Mrs. M , Aet. 45. Ascites and anasarca,
but not much otherwise diseased, and well enough to walk about
the house, and see after her family affairs. I thought this a
fair case for a trial of the Digitalis, and therefore directed a de-
coction of the fresh leaves, the stock of dried ones being ex-
hausted. About a week afterwards, calling to see my patient,
I was informed that she was dead; that the third day after my
first visit she suddenly fell down, and expired. Upon enquiry
I found she had not taken any of the medicine; for the snow had
lain so deep upon the ground, that the apothecary had not been
able to procure it. Had (p. 18) the medicine been given in a
case seemingly so favourable as this, and had the patient died
under its use, is it not probable that the death would have been
attributed to it?
Case VII
February nth. Mr. E , of W . Aet. 61. Hydro-
thorax, ascites and anasarca, consequences of hard drinking. He
had. been attended for some time by a physician in his neighbour-
hood, who had treated his case with the usual remedies, but with-
out affording him any relief; nor could I expect to succeed better
by any other medicine than the Digitalis. The dried leaves were
not to be had; and the green ones at this season being very un-
certain in their strength, I ordered four ounces of the roots in a
pint decoction, and directed three spoonfuls to be given every
fourth hour, until it either excited nausea, or a free discharge
of urine; both these effects took place nearly at the same time:
he made a large quantity of water, the swellings subsided very
considerably, and his breath became easy. Eight days after-
wards he began upon a course of bitters and deobstruents. The
dropsical symptoms soon increased again, but he had suffered so
much from the severity of the sickness before, that he was neither
willing to take, nor I to give the same medicine again.
Perhaps this patient might have been saved, if I had been well
acquainted with the management and (p. 19) real doses of the
326 Medical Classics
medicine, which was certainly in this instance made very much
too strong; and notwithstanding the caution to stop the further
exhibition when certain effects should take place, it seems the
quantity previously swallowed was sufficient to distress him ex-
ceedingly.
Case VIII
March nth. Mrs. H , Aet. 32. A few days after a tedi-
ous labour, had her legs and thighs swelled to a very great degree;
pale and semi-transparent,* with pain in both groins. After a
purge of calomel and rhubarb, ung. mere, was ordered to be
rubbed upon the groins, and the following decoction was directed:
R. Fol. Digital, purp. recent, oz. ii.
Aq. purae. lbi. coque ad lbiss et colatur. adde.
Aq. cinn. sp. oz. iv. M. capita, cyath. vinos, parv. bis
quotidie.
The decoction presently increased the secretion of urine, and
abated the distension of the legs: in a fortnight the swelling was
gone; but some days after leaving her bed, her legs swelled again
about the ancles, which was removed by another bottle of the
decoction on the 21st of April.
(p. 20) Case IX
March 29th. Mr. G , Aet. 47. Very much deformed;
asthma of several years continuance, but now dropsical to a
great degree. Took several medicines without relief, and then
tried the Digitalis, but with no better success.
Case X
April 10th. G G , Aet. 70. Asthma and anasarca.
Took a decoction of the fresh leaves of the Digitalis, which pro-
duced violent sickness, but no immediate evacuation of water.
After the sickness had ceased altogether, the urine began to flow
copiously, and he was cured.
This disease has lately been vrell described by Mr. White, of Manchester.
The Foxglove 327
Case XI
July loth. Mr. M of T Aet. 54. A very hard
drinker; had been affected since November last with ascites and
anasarca, for which he had taken several medicines without bene-
fit. A decoction of the recent leaves of the Digitalis was then
directed, an ounce and half to a pint, one eighth of which I
ordered to be given every fourth hour. A few doses brought on
great nausea, indistinct vision, and a great flow of urine, so as
presently to empty him of all the dropsical water. Indeed the
evacuation was so rapid and so complete, that it became neces-
sary to apply a bandage round the belly, and to support him with
cordials.
(p. ai) In something more than a year and a half, his dropsy
returned, but the Digitalis did not then succeed to our wishes.
In August , 1779, he was tapped, and lived afterwards only about
five weeks.
For more particulars, see the extract of a letter from Mr.
Lyon.
Case XII
September 12th. Miss C of T , Aet. 48. An ovarium
dropsy, and anasarcous legs and thighs. For three months in
the beginning of this year she had been under the care of Dr.
Darwin, who at different times had given her blue vitriol, ela-
terium, and calomel; decoction of pareira brava, and guiacum
wood, with tincture of cantharides; oxymel of squills, decoction
of parsley roots, &c. Finding no relief, she discontinued the use
of medicines, until the urgency of her symptoms induced her to
ask my advice about the end of August. She was greatly emaci-
ated, and had almost a total loss of appetite. I first tried small
doses of Merc, sublim. corr. in solution, with decoction of burdock
roots, and blisters to the thighs. No advantage attending the
use of this plan, I directed a decoction of Fol. Digit, a dram and a
half to a pint; one ounce to be taken twice a day. It presently
reduced the anasarcous swellings, but made no alteration in the
distension of the abdomen.
3 28
Medical Classics
(p. 22) Case XIII
October 9th. Mrs. B Aet. 40. An ovarium dropsy.
Took a decoction of Digitalis without effect. Her life was pre-
served for some years by repeated tapping.
* 77 *
Case XIV
February Bth. Mr. R of K . Had formerly suffered
much from gout, and lived very intemperately. Jaundiced
countenance; ascites; legs and thighs greatly swollen; appetite
none; extremely weak; confined to his bed. Had taken many
medicines from his apothecary without advantage. I ordered
him decoction of Digitalis, and a cordial; but he survived only a
few days.
Case XV
March 13th. Mr. M , Aet. 54. A thorax greatly de-
formed; asthma through the winter, succeeded by dropsy in
belly and legs. Pulse very small; face leaden coloured; cough
almost continual. Decoction of seneka was directed, and small
doses of Dover’s powder at night.
17th. Gum-ammoniac and squill, with elixir parego. at night.
— 26th, Squill and decoction of seneka. — 30th. His complaints
still increasing, decoction (p. 23) of Digitalis was then directed,
which relieved him in a few days; but his complaints returned
again, and he died in the month of ’June .
Case XVI
August 1 8th. Mr. B , Aet. 33. Pulmonary consumption
and dropsy. The Digitalis, and that failing, other diuretics were
used, in hopes of gaining some relief from the distress occasioned
by the dropsical symptoms, but none of them were effectual. He
was then attended by another physician, and died in about two
months.
Case XVII .
September 21st. Mrs. M W G , Aet. 50. An
ovarium dropsy. She took half a pint of Infus. Digitalis, which
The Foxglove , 329
made her sick, but did not increase the quantity of urine. She
was afterwards relieved by tapping.
Case XVIII
October 28th. R W , Aet. 33. Ascites and universal
anasarca; countenance quite pale and bloated; appetite none,
and the little food he forces down is generally rejected.
R. Fol. Digit, purp. siccat. iii.
Aq. bull. lbi. digere per horas duas, et colat. adde aq.
junip. comp. oz. iii.
(p. 24) He was directed to take one ounce of this infusion every
two hours until it should make him sick. This was on Wednes-
day. The fifth dose made him vomit. On Thursday afternoon
he vomited again freely, without having taken any more of the
medicine. On Friday and Saturday he made more water than
he had done for a week before, and the swellings of his face and
body were considerably abated. He was directed to omit all
medicine so long as the urine continued to flow freely, and also
to keep an account of the quantity he made in twenty-four hours.
These were his reports:
October 31st. Saturday, 5 half pints.
November 1st. Sunday, 6
2d. Monday, 8
3d. Tuesday, 8
4th. Wednesday, 7
5 th. Thursday, 8
On Wednesday he began to purge, and the purging still con-
tinues, but his appetite is better than he has known it for a long
time. No swelling remains but about his ancles, extending at
night half way up his legs.
Omit all medicines at present.
7th. Saturday 7 | half pints.
8th. Sunday, 8
9th. Monday, 6 f
10th. Tuesday, 6 §
1 1 th. Wednesday, 6
1 2th. Thursday, 6 \
Medical Classics
33 °
(p. 25) On Tuesday the 17th, some swelling still remained about
his ancles, but he was in every other respect perfectly well.
He took a few more doses of the infusion, and no other medi-
cine.
Case XIX
December 8 th. W B , Aet. 60. A hard drinker. Dis-
eased viscera; ascites and anasarca. An infusion of Digitalis
was directed, but it had no other effect than to make him sick.
1779
In the beginning of this year we had many dropsies in children,
who had suffered from the Scarlatine Anginosa; they all yielded
very readily to the Digitalis, but in some the medicine purged,
and then it did not prove diuretic, nor did it remove the dropsy
until opium was joined with it, so as to prevent it purging. — I
did not keep notes of these cases, but I do not recollect a single
instance in which the Digitalis failed to effect a cure.
Case XX
January 1st. Mr. H . Hydrops Pectoris; legs and thighs
prodigiously anasarcous; a very distressing sense of fulness and
tightness across his stomach; urine in small quantity; pulse in-
termitting; breath very short.
(p. 26) He had taken various medicines, and been blistered,
but without relief. His complaints continuing to increase, I
directed an infustion of Digitalis, which made him very sick;
acted powerfully as a diuretic, and removed all his symptoms.
About three months afterwards he was out upon a journey,
and, after taking cold, was suddenly seized with difficulty of
breathing, and violent palpitation oPhis heart: he sent for me,
and I ordered the infusion as before, which very soon removed
his complaints. He is now active and well; but, whenever he
takes cold, finds some return of difficult breathing, which he
soon removes by a dose or two of the infusion.
Case XXI
January 5th. Mrs. M , Aet. 69. Hydrothorax, (called
asthma) ascites and anasarca. I directed an infusion of Fol.
The Foxglove 331
Digital, siccat. three drams to a pint; a small wine glass to be
taken every third or fourth hour. It made her violently sick,
acted powerfully as a diuretic, set her breath perfectly at liberty,
and carried off the swelling of her legs; when she was nearly emp-
tied, she became so languid, that I thought it necessary to order
cordials, and a large blister to her back. Mr. Ward, who at-
tended as her apothecary, tells me she had some return of her
asthma in June and October following, which was each time re-
moved by the same medicine.
(p. 27) Case XXII
January nth. Mr. H , Aet. 59. Ascites and general
anasarca. A large corpulent man, and a hard drinker: he had
repeatedly suffered under complaints of this kind, but had been
always relieved by the judicious assistance of Dr. Ash. In the
present instance, however, not finding relief as usual from the
prescriptions of my worthy friend, he sent for me; after examining
into his situation, and informing myself what had been done to
relieve him, I was satisfied that the Digitalis was the only medi-
cine from which I had any thing to hope. It was therefore di-
rected; but another patient requiring my assistance at a distance
from town, I desired he would not begin the medicine before I
returned, which would be early on the third day; for I was well
aware of the difficulties before me, and that he would inevitably
sink under too rapid an evacuation of the water. On my return
I was informed, that the preceding evening, as he sat on his chair,
his head sunk upon his breast, and he died.
This case, as well as case VI. is mentioned with a view to dem-
onstrate to younger practitioners, how sudden and unexpected
the deaths of dropsical patients sometimes happen, and how
cautious we should be in assigning causes for effects.
Case XXIII
August 31st. Mr. C , Aet. 57. Diseased viscera, jaun-
dice, ascites and anasarca. After trying (p. 28) calomel, saline
draughts, jallap purges, chrystals of tartar, pills of gum am-
moniac, squills, and soap, sal succini, eleterium, & c. infusion of
Medical Classics
332
Digitalis was directed, which removed all his urgent symptoms,
and he recovered a pretty good state of health.
Case XXIV
September nth. I was desired to visit Mr. L , Aet. 63;
a middle sized man; rather thin; not habitually intemperate;
found him in bed, where he had been for three days. He was in
a state of furious insanity, and had been gradually losing his
reason for ten days before, but was not outrageous the first week:
his apothecary had given him ten grains of emetic tartar, a dram
of ipecacoanha, and an ounce of tincture of jallap, in the space of
a few hours, which scarcely made him sick, and only occasioned a
stool or two upon enquiring into the usual state of his health,
I was told that he had been troubled with some difficulty of
breathing for thirty years past, but for the nine last years this
complaint had increased, so that he was often obliged to sit up
the greater part of the night; and, for the last year, the sense of
suffocation was so great, when he lay down, that he often sat up
for a week together. His father died of an asthma before he
was fifty. A few years ago, at an election, where he drank more
than usual, his head was affected as now, but in a slighter degree,
and his asthmatic symptoms banished; and now, notwithstanding
he has been several (p. 29) days in bed, he feels not the least
difficulty in breathing.
Apprehending that the insanity might be owing to the same
cause which had heretofore occasioned the asthma, and that this
cause was water; I ordered a decoction of the Fol. siccat Digital,
three drams to half a pint; three spoonfuls to be taken every
third hour: the fourth dose made him sick; the medicine was then
stopped; the sickness continued at intervals, more or less, for
four days, during which time he made a great quantity of water,
and gradually became more rational. On the fifth day his ap-
petite began to return, and the sickness ceased, but the flow of
urine still continued.
A week afterwards I saw him again, and examined him partic-
ularly; his head was then perfectly rational, appetite very good,
breath quite easy, permitting him to lie down in bed without
The Foxglove 333
inconvenience, makes plenty of water, coughs a little, and expec-
torates freely.- He took no other medicine, except a little rhu-
barb when costive.
Case XXV
September 15th. Mr. J. R , Aet. 50. Subject to an asth-
matical complaint for more than twenty years, but was this
year much worse than usual, and symptoms of dropsy appeared.
In July he took G. ammon. squill and seneka, with infus. amarum
and fossil alkaly. In August infusum amar. (p. 30) with vin.
chalyb. and at bed-time pil. styr. and squill. His complaints
increasing, the squill was pushed as far as could be borne, but
without any good effect. September 15th, an infusion of Digi-
talis was directed, but he died the next morning.
Case XXVI
September 18th. Mrs. R , Aet. 30. After a severe child-
bearing, found both her legs and thighs swelled to the utmost
stretch of the skin. They looked pale, and almost transparent.
The case being similar to that related at No. VIII. I determined
upon a similar method of treatment, but as this patient had an
inflammatory sore throat also, I wished to get that removed
first, and in three or four days it was done. I then directed an
infusion of Digitalis, which soon increased the urinary secretion,
and reduced the swellings, without any disturbance of her
stomach.
A few days after quitting her bed and coming down stairs, some
degree of swelling in her legs returned, which was removed by
calomel, an opening electuary, and the application of rollers.
Case XXVII
October 7th. Mr. F , a little man, with a spine and thorax
greatly deformed; for more than a year past had complained of
difficult respiration, and a sense of fulness about his stomach;
these complaints increasing, his abdomen gradually enlarged,
(p. 31) and a fluctuation in it became perceptible. He had no
anasarca, no appearance of diseased viscera, and no great paucity
Medical Classics
334
of urine. Purges and diuretics of different kinds affording him
no relief, my assistance "was desired. After trying squill medi-
cines without effect, he was ordered to take Pulv. fol. Digital,
in small doses. These producing no sensible effect, the doses
were gradually increased until nausea was excited; but there was
no alteration in the quantity of urine, and consequently no relief
to his complaints. I then advised tapping, but he would not
hear of it; however, the distress occasioned by the increasing
fulness of his belly at length compelled him to submit to the oper-
ation on the 20th of November. It was necessary to draw off the
water again upon the following days:
December the 8 th.
— — 27th.
1780. February the 4th.
— — 23rd.
March the 9th.
During the intervals, no method I could think of was omitted
to prevent the return of the disease, but nothing seemed to avail.
In the operation of February 23rd, his strength was so much re-
duced, that the water was not entirely removed; and on the 9th
of March , before his belly was half emptied, notwithstanding,
the most judicious application of bandage, his debility was so
great, that it was judged prudent to stop. After being placed
in bed, the faintness and sickness continued; severe rigors (p. 32)
ensued, and violent vomiting; these vomitings continued through
the night, and in the intervals he lay in a state nearly approaching
to syncope. The next day I found him with nearly the same
symptoms, but remarked that the quantity of fluid he had thrown
up was very much more than what he had taken, and that his
abdomen was considerably fallen, in the course of two or three
days more, he discharged the whole of the effused fluid, his
strength and appetite gradually returned, and he was in all
respects much better than he had been before the last operation.
Some time afterwards, his belly began to fill again, and he
again applied to me; upon an accurate examination, I judged the
quantity of fluid might then be about four or five quarts. Nature
had pointed out the true method of cure in this case; I therefore
The Foxglove 335
ordered him to bed, and directed ipecacoanha vomits to be given
night and morning: in two or three days the whole of the water
was removed by vomiting, for he never purged, nor was the quan-
tity of his urine increased; his appetite and strength gradually
returned; he never had any further relapse, and is now an active
healthy man. I must leave the reader to make his own reflection
on this singular case.
(p. 33) 1780
Case XXVIII
January nth. Captain V , Aet. 42. Had suffered much
from residing in hot climates, and drinking very freely, partic-
ularly rum in large quantity. He had tried many physicians
before I saw him, but nothing relieved him. I found him greatly
emaciated, his countenance of a brownish yellow, no appetite,
extremely low, distressing fulness across his stomach; legs and
thighs greatly swollen; pulse quick, and very feeble; urine in
small quantity. As he had evidently only a few days to live,
I ordered him nothing but a solution of sal diureticus in cinnamon
water, slightly acidulated with syrup of lemons. This medicine
effecting no change, and his symptoms becoming daily more
distressing, I directed an infusion of Digitalis. A few doses
occasioned a copious flow of urine, without sickness or any other
disturbance. The medicine was discontinued; and the next day
the urine continuing to be secreted very plentifully, he lost his
most distressing complaints, was in great spirits, and ate a pretty
good dinner. In the evening, as he was conversing cheerfully
with some friends, he stooped forwards, fell from his chair, and
died instantly. Had he been in bed, I think there is reason to
believe this fatal syncope, if such it was, would not have hap-
pened.
(p. 34) Case XXIX
February 6th. Mr. H , Aet. 63. A corpulent man: had
suffered much from gout, which for the last year or two had
formed very imperfectly. He had now symptoms of water in
Medical Classics
3 3 6
his chest, his belly and his legs. An infusion of Digitalis re-
moved these complaints, and after being confined for the greater
part of the winter, he was well enough to get abroad again. In
the course of a month the dropsical symptoms returned, and were
again removed by the same medicine. Bitters and tonics were
now occasionally prescribed, but his debility gradually increased,
and he died some time afterwards; but the dropsy never returned.
Case XXX
February 17th. Mr. D , Aet. 50. Ascites and anasarca,
with symptoms of phthisis. He had been a very hard drinker.
The infusum Digitalis removed his dropsical symptoms, and he
was sufficiently recovered to take a journey; but as the spring
advanced, the consumptive symptoms increased, and he died
soon afterwards, perfectly emaciated.
Case XXXI
March 5th. I was desired to visit Mrs. H , a very delicate
woman, who after a severe lying-in, had her legs and thighs swol-
len to a very great degree; (p. 35) pale and semi-transparent. I
found her extremely faint, her pulse very small and slow; vomiting
violently, and frequently purging. She was attended by a
gentleman who had seen me give the Digitalis in a similar case
of swelled legs after a lying-in (see Case XXVI.) about six months
before. He had not considered that this patient was delicate,
the other robust; nor had he attended to stop the exhibition of
the medicine when its effects began to take place. The great
distress of her situation was evidently owing to the imprudent
and unlimited use of the Digitalis. I was very apprehensive for
her safety; ordered her cordials and volatiles; a free supply of
wine, chamomile tea with brandy for common drink, and blisters.
The next day the situation of things was much the same, but
with all this disturbance no increased secretion of urine. The
same methods were continued; an opiate ordered at night, and
liniment, volatile upon flannel applied to the groins, and she now
complained of great pain in those parts. The third day the
nausea was less urgent, the vomitings less frequent, the pulse
The Foxglove 337
not so slow. Camphorated spirit, with caustic volatile alkaly,
was applied to the stomach, emulsion given for common drink,
and the same medicines repeated. From this time, the intervals
became gradually longer between the fits of vomiting, the flow
of urine increased, the swellings subsided, the appetite returned,
and she recovered perfectly.
(p. 36) Case XXXII
March 1 6th. Mr. D , Aet. 70. A paralytic stroke had
for some weeks past impaired the use of his left side, and he com-
plained much of his breath, and of a straitness across his stom-
ach; at length, an anasarca and ascites appearing, I had no doubt
as to the cause of the former symptoms; but, upon account of
his advanced age, and the paralytic affection, I hesitated to give
the Digitalis, and therefore tried the other usual modes of prac-
tice, until at length his breath would not permit him to lie down
in bed, and his other symptoms increased so rapidly as to threaten
a speedy dissolution. In this dilemma I ventured to prescribe
an infusion of the Fol. siccat. Digital, which presently excited a
copious flow of urine, and made him very sick; a strong infusion
of chamomile flowers, with brandy, relieved the sickness, but the
diuretic effects of the Digitalis continuing, his dropsy was re-
moved, and his breathing became easy. The palsy remained
nearly in the same state. He lived until August 1782, and with-
out any return of the dropsy.
Case XXXIII
March 18th. Miss S , Aet. 5. Hydrocephalus internus.
As the case did not yield to calomel, when matters were nearly
advanced to extremities, it occurred to me to try the Infusum
Digitalis; a few doses of which were given, but had no sensible
effect.
(p. 37) Case XXXIV
March 19th. A young lady, soon after the birth of an illegiti-
mate child, became insane. After being nearly a month under my
care, swellings of her legs, which at first had been attributed to
weakness, extended to her thighs and belly; her urine became foul.
338 Medical Classics
and small in quantity, and the insanity remained nearly the same.
As it had been very difficult to procure evacuations by any means,
I ordered half an ounce of Fol. Digital.' siccat. in a pint infusion,
and directed two spoonfuls to be given every two hours: this had
the desired effect; the dropsy and the insanity disappeared to-
gether, and she had afterwards no other medicine but some aperi-
ent pills to take occasionally.
Case XXXV
April 1 ath. Mr. R , Aet. 3 2. For the last three or four
years had had more or less of what was considered as asthma;
— it appeared to me Hydrothorax. I directed an infusion of
Digitalis, which presently removed his complaints. In June
following he had a relapse, and took two grains of Pulv. fol.
Digit, three times a day, which cured him after taking forty
grains, and he has never had a return.
(p. 38) Case XXXVI
May 15th. Mrs. H , Aet. 40. A spasmodic asthma,
attended with symptoms of effusion. An infusion of Digitalis
relieved her very considerably, and she lived four years after-
wards without any relapse.
Case XXXVII
May 26th. R B , Aet. 12. Scrophulus, consumptive,
and at length anasarcous. Took Infus. Digital, without advan-
tage. Died the July following.
Case XXXVIII
June 4th. Mrs. S , of W , Aet. 49. Ascites and ana-
sarca. Had taken many medicines; first from her apothecary,
afterwards by the direction of a very judicious and very cele-
brated physician, but nothing retarded the increase of the dropsy.
I first saw her along with the physician mentioned above, on the
14th of May ; we directed an electuary of chrystals of tartar, and
Seltzer water for common drink; this plan failing, as others had
done before, we ordered the Infus. Digital, which in a few days
The Foxglove 339
nearly removed the dropsy. I then left her to the care of her
physician; but her constitution was too much impaired to admit
of restoration to healthy and I understand she died a few weeks
afterwards.
(p. 39) Case XXXIX
June 13th. Mr. P , Aet. 35. A very hard drinker, was
attacked with a severe haemoptoe, which was followed by ascites
and anasarca. He had every appearance of diseased viscera, and
his urine was small in quantity. The power and the infusion of
Digitalis were given at different times, but without the desired
effect. Other medicines were tried, but in vain. Tapping pro-
longed his existence a few weeks, and he died early in the follow-
ing autumn.
Case XL
June 27th. Mr. W , Aet. 37. An apparently asthmatic
affection, gradually increasing for three or four years, which
not yielding to the usual remedies, he took the infusion of Digi-
talis. Two or three doses made him very sick; but he thought his
breathing relieved. After one week he took it again, and was
so much better as to want no other medicine.
In the course of the following winter he became hectic, and
died consumptive about a year afterward.
Case XLI
July 6th. Mr. E , Aet. 57. Hydrothorax and anasarca;
his breath so short that he could not (p. 40) lie down. After a
trial of squill, fixed alkaly, and dulcified spirit of nitre, I directed
Pulv. Digital, gr. 2, thrice a day. In four days he was able to
come down stairs; in three days more no appearance of disease
remained; and under the use of aromatics and small doses of
opium, he soon recovered his strength.
Case XLII
July 7th. Miss H , of T , Aet. 39. In the last state
of phthisis pulmonalis became dropsical. She took the Digitalis
without being relieved.
34-0
Medical Classics
Case XLIII
July 9th. Mrs. F , Aet. 70. A chearful, strong, healthy
woman; but for a few years back had experienced a degree of
difficult breathing when in exercise. In the course of the last
year her legs swelled, and she felt great fulness about her stom-
ach. These symptoms continued increasing very fast, notwith-
standing several attempts made by a very judicious apothecary
to relieve her. The more regular practitioner failing, she had
recourse to a quack, who I believe plied her very powerfully with
Daphne laureola, or some drastic purge of that kind. I found
her greatly reduced in strength, her belly and lower extremities
swollen to an amazing size, her urine small in quantity, and her
appetite greatly impaired. For the first fortnight of my attend-
ance blisters were applied, solution of fixed alkaly, decoction of
seneka with vitriolic aether, (p. 41) chrystals of tartar, squill and
cordial medicines were successively exhibited, but with no ad-
vantage. I then directed Pulv. Fol. Digital, two grains every
four hours. After taking eighteen grains, the urine began to
increase. The medicine was then stopped. The discharge of
urine continued to increase, and in five or six days the whole of
the dropsical water passed off, without any disturbance to the
stomach or bowels. As the distension of the belly had been very
great, a swathe was applied, and drawn gradually tighter as the
water was evacuated. As no pains were spared to prevent the
return of the dropsy, and as the best means I could devise proved
unequal to my wishes, both in this and in some other cases, I
shall take the liberty to point out the methods I tried at different
times in as concise a manner as possible, for the knowledge of
what will not do, may sometimes assist us to discover what will.
1780.
July 1 8th. Infusum amarum, stell, Seltzer water.
September 22d. Neutral saline draughts, with tinct. canthar.
26th. Pills of soap, garlic and millepedes.
30th. The same pills, with infusum amarum.
October nth. Pills of aloes, assafetida, and sal martis, in the
day-time, and mercury rubbed down, at night.
December 21st. The accumulation of water now required a repeti-
The Foxglove 341
tion of the Digitalis. It was directed in infusion, a dram and
half to eight ounces, and an ounce and half given every
fourth hour, (p. 42) until its effects began to appear. The
water was soon carried off.
30th. Sal diuretic, twice a day. To eat preserved garlic fre-
quently.
1781.
February 1st. Pills of calomel, squill and gum ammoniac.
3d. Infusion of Digitalis repeated, and after the water was
carried off, Dover’s powder was tried as a sudorific.
March 18th. Infus. Digital, repeated.
26th. Pills of sal martis and aromatic species, with infusum
am arum.
May 5th. Being feverish; James’s powder and saline draughts.
10th. Laudanum every night, and an opening tincture to ob-
viate costiveness.
24th. Infus. Digitalis, one ounce only every fourth hour, which
soon procured a perfect evacuation of the water.
August nth. Infus. Digitalis.
October 19th. An emetic, and fol. Cicut. pulv. ten grains every
six hours.
November 8th. A mercurial bolus at bed-time.
16th. Infus. Digitalis.
December 23d. An emetic — Pills of seneka and gum ammoniac —
Vitriolic acid in every thing she drinks.
25th. Squill united to small doses of opium.
1782.
January 2d. A troublesome cough — Syrup of garlic and oxymel
of squills. A blister to the back.
4th. Tincture of cantharides and paregoric elixir, (p. 43)
28th. Infus. Digitalis, half an ounce every morning, and one
ounce every night, was now sufficient to empty her.
March 26th. Infus. Digitalis; and when emptied, vitriol of
copper twice a day.
April 1st. A cordial mixture for occasional use.
Two months afterwards a purging came on, which every now and
then returned, inducing great weakness — her appetite failed,
and she died in July.
34-2
Medical Classics
Intervals
From July 9th, 1780, to December 21st, 171 days.
From December 21st to February 3d, 1781, 34 days.
From February 3d to March 18th, 44 days.
From March 18th to May 24th, 66 days.
From May 24th to August nth, 79 days.
From August nth to November 16th, 98 days.
From November 16th to January 28th, 1782, 74 days.
From Ja?iuary 28th to March 26th, 57 days.
None of the accumulations of water were at all equal to that
which existed when I first saw her, for finding so easy a mode of
relief, she became impatient under a small degree of pressure,
and often insisted upon taking her medicine sooner than I thought
it necessary. After the 26th of March the degree of effusion was
inconsiderable, and at the time of her death very trifling, being
probably carried off by the diarrhoea, (p. 44)
Case XLIV
July 1 2th. Mr. H , of A , Aet. 60. In the last stage
of a life hurried to a termination by free living, dropsical symp-
toms became the most distressing. He wished to take the Digi-
talis. It was given, but afforded no relief.
Case XLV
July 13th. Mr. S , Aet. 49. Asthma, or rather hydro-
thorax, anasarca, and symptoms of a diseased liver. He was
directed to take two grains of Pulv. fol. Digital, every two hours,
until it produced some effect. It soon removed the dropsical
and asthmatic affections, and steel, with Seltzer water, restored
him to health.
Case XLV I
August 6th. Mr. L , Aet. 35. Ascites and anasarca.
Pulv. Digital, grains three, repeated every fourth hour, until
he had taken two scruples, removed every appearance of dropsy
in a few days. He was then directed to take solution of mere,
sublimat. and soon recovered his health and strength.
The Foxglove 343
Case XLVII
August 1 6th. Mr. G , of W , Aet. 86. Asthma of
many years duration, and lately an incipient anasarca, with a
paucity of urine. He had never lived in temperately, was of a
chearful disposition, and very sensible: for some years back had
(p. 45) lost all relish for animal food, and his only support had
been an ounce or two of bread and cheese, or a small slice of seed-
cake, with three or four pints of mild ale, in the twenty-four
hours. After trying chrystals of tartar, fixed alkaly, squills,
&c. I directed three grains of Pulv. fol. Digital, made into pills,
with G. ammoniac, to be given every six hours; this presently
occasioned copious discharges of urine, removed his swellings,
and restored him to his usual standard of health.
Case XLVIII
August 17th. T B , Esq. of K , Aet. 46. Jaun-
dice, dropsy, and great hardness in the region of the liver. In-
fusion of Digitalis carried off all the effusion, and afterwards a
course of deobstruent and tonic medicines removed his other com-
plaints.
Case XLIX
August 23 d. Mr. C Aet. 58. (The person mentioned at
Case XXIII.) He had continued free from dropsy until within
the last six weeks, his appetite was now totally gone, his strength
extremely reduced, and the yellow of his jaundice changed to a
blackish hue. The Digitalis was now tried in vain, and he died
shortly afterwards.
Case L
August 24th. Mrs. W , Aet. 39. Anasarcous legs and
symptoms of hydrothorax, consequent (p. 46) to a tertian ague.
Three grains of Pulv. Digitalis, given every fourth hour, oc-
casioned a very copious flow of urine, and she got well without
any other medicine.
344
Medical Classics
Case LI
August 2.8th. Mr. J H , Aet. 27. In consequence of
very free living, had an ascites and swelled legs. I ordered him
to take two grains of Fol. Digital, pulv. every two hours, until
it produced some effect; a few doses caused a plentiful secretion
of urine, but no sickness, or purging: in six days the swellings
disappeared, and he has since remained in good health.
Case LII
September 27th. Mr. S , Aet. 45. Had been long in an
ill state of health, from what had been supposed an irregular
gout, was greatly emaciated, had a sallow complexion, no appe-
tite, costive bowels, quick and feeble pulse. The cause of his
complaints was involved in obscurity; but I suspected the poison
of lead, and was strengthened in this suspicion, upon finding
his wife had likewise ill health, and, at times, severe attacks of
colic; but the answers to my enquiries seemed to prove my
suspicions fruitless, and, amongst other things, I was told the
pump was of wood. He had lately suffered extremely from diffi-
cult breathing, which I thought owing to anasarcous lungs;
there was also a slight degree of pale swelling in his legs. Pulv.
(P- 47 ) f°h Digital, made into pills, with gum ammoniac and
aromatic species, soon relieved his breathing. Attempts were
then made to assist him in other respects, but with little good
effect, and some months afterwards he died, with every appear-
ance of a worn out constitution.
About two years after this gentleman’s death, I was talking
to a pump-maker, who, in the course of conversation, mentioned
the corrosion of leaden pumps, by some of the water in this
town, and instanced that at the house of Mr. S , which he had
replaced with a wooden one about three years before. The lead,
he said, was eaten away, so as to be very thin in some places,
and full of holes in others; — this accidental information explained
the mystery.
The deleterious effects of lead seem to be considerably modified
by the constitution of the patient; for in some families only one
or two individuals shall suffer from it, whilst the rest receive it
with impunity. In the spring of the year 1776, I was desired
The Foxglove 345
to visit Mrs. H , of S Park, who had repeatedly been
attacked with painful colics, and had suffered much from in-
superable costiveness; I suspected lead to be the cause of her
complaints, but was unable to trace by what means it was taken.
She was relieved by the usual methods; but, a few months after-
wards, I was desired to see her again : her sufferings were the same
as before, and notwithstanding every precaution to guard against
costiveness, she was never in perfect health, and seldom (p. 48)
escaped severe attacks twice or trice in a year; she had also fre-
quent pains in her joints. I could not find any traces of similar
complaints either in Mr. H , the children, or the servants.
Mrs. H was a water drinker, and seldom tasted any fer-
mented liquor. The pump was of wood, as I had been informed
upon my first visit. Her health continued nearly in the same
state for two or three years more, but she always found herself
better if she left her own house for any length of time. At
length it occurred to me, that though the pump was a wooden
one, the piston might work in lead. I therefore ordered the
pump rods to be drawn up, and upon examination with a mag-
nifying glass, found the leather of the piston covered with an
infinite number of very minute shining particles of lead. Per-
haps in this instance the metal was so minutely divided by abra-
sion, as to be mechanically suspended in the water. The lady
was directed to drink the water of a spring, and never to swallow
that from the pump. The event confirmed my suspicions, for
she gradually recovered a good state of health, lost the obstinate
costiveness, and has never to this day had any attack of the colic.
Case LIII
September a8th. Mrs. J , Aet. 70. Ascites and very thick
anasarcous legs and thighs, total loss of strength and appetite.
Infusion of Digitalis was given, but, as had been prognosticated,
with no good effect.
(p. 49) Case LIV
September 3°th. Mr. A , Aet. 57. A strong man; hydro-
thorax and swelled legs; in other respects not unhealthful. He
was directed to take two grains of the Pulv. fol. Digit, made into
34.6 Medical Classics
a pill with gum ammoniac. Forty grains thus taken at inter-
vals, effected a cure by increasing the quantity of urine, and he
has had no relapse.
Case LV
November 2d. Mr. P , of T , Aet. 42. A very strong
man, drank a great quantity of strong ale, and was much exposed
to alterations of heat and cold. About the end of summer
found himself short winded, and lost his appetite. The dyspnoea
gradually increased, he got a most distressing sense of tightness
across his stomach, his urine was little, and high coloured, and
his legs began to swell; his pulse slender and feeble. From the
20th of September I frequently saw him, and observed a gradual
and regular increase of all his complaints, notwithstanding the
use of the most powerful medicines I could prescribe. He took
chrystals of tartar, seneka, gum ammoniac, saline draughts,
emetics, tinct. of cantharides, spirits of nitre dulcified, squills
in all forms, volatile alkaly, calomel, Dover’s powder, &c. Blis-
ters and drastic purgatives were tried, interposing salt of steel
and gentian. I had all along felt a reluctance to prescribe the
Digitalis in this case, from a persuasion that it would not suc-
ceed. (p. 50) At length I was compelled to it, and directed one
grain to be given every two hours until it should excite nausea.
This it did; but, as I expected, it did no more. The reason of this
belief will be mentioned hereafter. Five days after this last trial
I gave him assafetida in large quantity, flattered by a hope that
his extreme sufferings from the state of his respiration, might
perhaps arise in part from spasm, but my hopes were in vain. I
now thought of using an infusion of tobacco, and prescribed the
following:
R. Fol. Nicotian, incis. drams ii.
Aq. bull. lb. ss.
Sp. Vini rectif. oz. i digere per horam.
I directed a spoonful of this to be given every two hours until
it should vomit. This medicine had no better effect than the
former ones, and he died some days afterwards.
347
The Foxglove
Case LVI
November 6th. Mr. H , Aet. 47. In the last state of
phthisis pulmonalis, suffered much from dyspnoea, and anasarca.
Squill medicines gave no relief. Digitalis in pills, with gum
ammon, purged him, but opium being added, that effect ceased,
and he continued to be relieved by them as long as he lived.
(p. 51) Case LVI I
November 16th. Mrs. F , Aet. 53. In August last was
suddenly seized with epileptic fits, which continued to recur at
uncertain intervals. Her belly had long been larger than nat-
ural, but without any perceptible fluctuation. Her legs and
thighs swelled very considerably the beginning of this month,
and now there was evidently water in the abdomen. The medi-
cines hitherto in vain directed against the epileptic attacks, were
now suspended, and two grains of the Pulv. fol. Digital, directed
to be taken every six hours. The effects were most favourable,
and the dropsical symptoms were soon removed by copious uri-
nary discharges.
The attacks of epilepsy ceased soon afterwards. In February ,
1781, there was some return of the swellings, which were soon
removed, and she now enjoys very good health. Does not the
narrative of this case throw light upon the nature of the epilepsy
which sometimes attacks women, soon after the cessation of the
menstrual flux?
J/81
Case LVI I I
January 1st. Mrs. G , of H , Aet. 62. Ascites and
very large hard legs. After trying various medicines, under the
direction of a very able physician, I ordered her to take one grain
of Pulv. (p. 52) Digital, every six hours, but it produced no effect.
Other Medicines were then tried to as little purpose. About the
end of February, I directed an infusion of the Fol. Digital, but
with no better success. Other methods were thought of, but
none proved efficacious, and she died a few weeks afterwards.
34 &
Medical Classics
Case LIX
January 3d. Mrs. B ■, Aet. 53. Ascites, anasarca, and
jaundice. After a purge of calomel and jallap, was ordered the
Infusion of Digitalis: it acted kindly as a diuretic, and greatly
reduced her swellings. Other medicines were then administered,
with a view to her other complaints, but to no purpose, and she
died about a month afterwards.
Case LX
January 14th. Mr. B , of D . Jaundice and ascites,
the consequences of great intemperance. Extremely emaciated;
his tongue and fauces covered with apthous crusts, and his appe-
tite gone. He first took tincture of cantharides with infusum
amarum, then vitriolic salts, and various other medicines without
relief; Infusum Digitalis was given afterwards, but was equally
unsuccessful.
Case LXI
February 2d. I was desired by the late learned and ingenious
Dr. Groome, to visit Miss S , a (p. 53) young lady in the last
state of emaciation from a dropsy. Every probable means to
relieve her had been attempted by Dr. Groome, but to no purpose;
and she had undergone the operation of the paracentesis re-
peatedly. The Doctor knew, he said, that I had cured many
cases of dropsy, by the Digitalis, after the other more usual
methods had been attempted without success, and he wished this
lady to try that medicine under my direction; after examining
the patient, and enquiring into the history of the disease, I was
satisfied that the dropsy was , encysted, and that no medicine
could avail. The Digitalis, however, was directed, and she took
it, but without advantage. She had determined not to be tapped
again, and neither persuasion, nor distress from the distension,
could prevail upon her: I at length proposed to make an opening
into the sac, by means of a caustic, which was done under the
judicious management of Mr. Wainwright, surgeon, at Dudley.
The water was evacuated without any accident, and the patient
The Foxglove 349
afterwards let it out herself from time to time as the pressure of it
became troublesome, until she died at length perfectly exhausted.
Shiery. ■ Is there not a probability that this method, assisted
by bandage, might be used so as to effect a cure, in the earlier
stages of ovarium dropsy?
Case LXII
February 27th. Mrs. O , of T , Aet. 52, with a con-
stitution worn out by various complicated (p. 54) disorders, at
length became dropsical. The Digitalis was given in small doses,
in hopes of temporary benefit, and it did not fail to fulfil our ex-
pectations.
Case LXIII
March 16th. Mrs. P , Aet. 47. Great debility, pale
countenance, loss of appetite, legs swelled, urine of small quan-
tity. A dram of Fol. siccat. Digital, in a half pint infusion was
ordered, and an ounce of this infusion directed to be taken every
morning. Myrrh and steel were given at intervals. Her urine
soon increased, and the symptoms of dropsy disappeared.
Case LX IV
March 18th. Mr. W , in the last stage of a pulmonary
consumption became dropsical. The Digitalis was given, but
without any good effect.
Case LXV
April 6th. Mr. B , Aet. 63. For some years back had
complained of being asthmatical, and was not without suspicion
of diseased viscera. The last winter he had been mostly confined
to his house, became dropsical, lost his appetite, and his skin
and eyes turned yellow. By the use of medicines of the deob-
struent class he became less discoloured, and the hardness about
his stomach seemed to yield; but the ascites and anasarcous symp-
toms increased so as to oppress his breathing (p. 55) exceed-
ingly. Alkaline salts, and other diuretics failing of their effects,
I ordered him to take an infus. of Digitalis. It operated so
powerfully that it became necessary to support him with cordials
350 Medical Classics
and blisters, but it freed him from the dropsy, and his breath
became quite easy. He then took soap, rhubarb, tartar of vit-
riol, and steel, and gradually attained a good state of health,
■which he still continues to enjoy.
Case LXVI
April 8th. Mr. B , Aet. 60. A corpulent man, with a
stone in his bladder, from which at times his sufferings are ex-
treme. He had been affected with what was supposed to be an
asthma, for several years by fits, but through the last winter his
breath had been much worse than usual; universal anasarca
came on, and soon afterwards an ascites. Now his urine was
small and much saturated, the dysuria was more dreadful than
ever; his breath would not allow him to lie in bed, nor would
the dysuria permit him to sleep; in this distressful situation,
after having used other medicines to little purpose, I directed
an infusion of Digitalis to be given. When the quantity of
urine became more plentiful, the pain from his stone grew easier;
in a few days the dropsy and asthma disappeared, and he soon
regained his usual strength and health. Every year since,
there has been a tendency to a return of these complaints, but
he has recourse to the infusion, and immediately removes them.
(p. 56) Case LX VII
April 24th. Mr. M , of C , Aet, 57. Asthma, ana-
sarca, jaundice, and great hardness and straitness across the re-
gion of the stomach. After a free exhibition of neutral draughts,
alkaline salt, &c. the dropsy and difficult breathing remaining
the same, he took Infusum Digitalis, which removed those com-
plaints. He never lost the hardness about his stomach, but en-
joyed very tolerable health for three years afterwards, without
any return of the dropsy.
Case LXVIII
April 25th. Mrs. J , Aet. 42. Phthisis pulmonalis and
anasarcous legs and thighs. She took the Infusum Digitalis
without effect. Myrrh and steel, with fixed alkaly, were then
ordered, but to no purpose.
The Foxglove 351
Case LXIX
May 1st. Master W , of St. , Aet. 6. I found him
with every symptom of hydrocephalus intemus. As it was yet
early in the disease, in consequence of ideas which will be men-
tioned hereafter, I directed six ounces of blood to be immediately
taken from the arm; the temporal artery to be opened the suc-
ceeding day; the head to be shaven, and six pints of cold water to
be poured upon it every fourth hour, and two scruples of strong
mercurial (p. 57) ointment to be rubbed into the legs every day.
Five days afterwards, finding the febrile symptoms very much
abated, and judging the remaining disease to be the effect of
effusion, I directed a scruple of Fol. Digital, siccat. to be infused
in three ounces of water, and a tablespoonful of the infusion to
be given every third or fourth hour, until its action should be
someway sensible. The effect was, an increased secretion of
urine; and the patient soon recovered.
Case LXX
May 3d. Mrs. B , Aet. 59. Ascites and anasarca, with
strong symptoms of diseased viscera. Infusum Digitalis was at
first prescribed, and presently removed the dropsy. She was
then put upon saline draughts and calomel. After some time
she became feverish: the fever proved intermittent, and was
cured by the bark.
Case LXXI
May 3d. Mr. S , Aet. 48. A strong man, who had lived
intemperately. For some time past his breath had been very
short, his legs swollen towards evening, and his urine small in
quantity. Eight ounces of the Infus. Digitalis caused a con-
siderable flow of urine; his complaints gradually vanished, and
did not return.
(p. 58) Case LXXII
May 24th. Joseph B , Aet. 50. Ascites, anasarca, and
jaundice, from intemperate living. Infusion of Digitalis pro-
duced nausea, and lowered the frequency of the pulse; but had
2 52 Medical Classics
no other sensible effects. His disorder continued to increase,
and killed him about two months afterwards.
Case LXXIII
June 29th. Mr. B , Aet. 60. A hard drinker; afflicted
with asthma, jaundice, and dropsy. His appetite gone; his
water foul and in small quantity. Neutral saline mixture, chrys-
tals of tartar, vinum chalybeat. and other medicines had been
prescribed to little advantage. Infusion of Fol. Digitalis acted
powerfully as a diuretic, and removed the most urgent of his
complaints, viz. the dropsical and asthmatical symptoms.
The following winter his breathing grew bad again, his appe-
tite totally failed, and he died, but without any return of the
ascites.
Case LXXIV
June 29th. Mr. A , Aet. 58. Kept a public house and
drank very hard. He had symptoms of diseased viscera, jaun-
dice, ascites, and anasarca. After taking various deobstruents
and diuretics, to no purpose, he was ordered the Infusion of
Digitalis: (p. 59) a few doses occasioned a plentiful flow of urine,
relieved his breath, and reduced his swellings; but, on account of
his great weakness, it was judged imprudent to urge the medicine
to the entire evacuation of the water. He was so much relieved
as to be able to come down stairs and to walk about, but his want
of appetite and jaundice continuing, and his debility increasing,
he died in about two months.
Case LXXV
July 1 8th. Mrs. B , Aet. 46. A little woman, and very
much deformed. Asthmatical for many years. For several
months past had been "worse than usual; appetite totally gone,
legs swollen, sense of great fulness about her stomach, coun-
tenance fallen, lips livid, could not lie down.
The usual modes of practice failing, the Digitalis was tried,
but w T ith no better success, and in about a month she died; not
without suspicion of her death having been accelerated a few
The Foxglove 353
days, by her taking half a grain of opium. This may be a cau-
tion to young practitioners to be careful how they venture upon
even small doses of opium in such constitutions, however much
they may be urged by the patient to prescribe something that
may procure a little rest and ease.
(p. 60) Case LXXVI
August 1 2th. Mr. L , Aet. 65, the person whose Case is
recorded at No. XXIV, had a return of his insanity, after near
two years perfect health. He was extremely reduced when I
saw him, and the medicine which cured him before was now ad-
ministered without effect, for his weakness was such that I did
not dare to urge it.
Case LXXVI I
September ioth. Mr. V , of S , Aet. 47. A man of
strong fibre, and the remains of a florid complexion. His disease
an ascites and swelled legs, the consequence of a very free course
of life; he had been once tapped, and taken much medicine before
I saw him. The Digitalis was now directed; it lowered his pulse,
but did not prove diuretic. He returned home, and soon after
was tapped again, but survived the operation only a few hours.
Case LXXVI I I
September 25th. Mr. O , of M , Aet. 63. Very pain-
ful and general swellings in all his limbs, which had confined him
mostly to his bed since the preceding winter; the swellings were
uniform, tense, and resisting, but the skin not discoloured. After
trying guiacum and Dover’s powder without advantage, I
directed Infusion of Digitalis. It acted on the kidneys, but did
not relieve him. It is not (p. 61) easy to say what the disease
was, and the patient living at a distance, I never learnt the future
progress or termination of it.
Case LXXIX
September 26th. Mr. D , Aet. 42, a very sensible and judi-
cious surgeon at B , in Staffordshire, laboured under ascites
354 Medical Classics
and very large anasarcous legs, together with indubitable symp-
toms of diseased viscera. Having tried the usual diuretics to no
purpose, I directed a scruple of Fol. Digital, sicat. in a four ounce
infusion, a table spoonful to be taken twice a day. The second
bottle wholly removed his dropsy, which never returned.
Case LXXX
September 27th. Mrs. E , Aet. 42. A fat sedentary
woman; after a long illness, very indistinctly marked; had symp-
toms of enlarged liver and dropsy. In this case I was happy in
the assistance of Dr. Ash. Digitalis was once exhibited in small
doses, but to no better purpose than many other medicines.
She suffered great pain in the abdomen for several weeks, and
after her death, the liver, spleen, and kidneys were found of a
pale colour, and very greatly enlarged, but the quantity of effused
fluid in the cavity was not more than a pint.
(p. 62) Case LXXXI
October 28th. Mr. B , Aet. 33. Had drank an immense
quantity of mild ale, and was now become dropsical. He was a
lusty man, of a pale complexion: his belly large, and his legs and
thighs swollen to an enormous size. I directed the Infusion of
Digitalis, which in ten days completely emptied him. He was
then put upon the use of steel and bitters, and directed to live
temperately, which I believe he did, for I saw him two years
afterwards in perfect health.
Case LXXXII
November 14th. Mr. W , of T , Aet. 49. A lusty man,
with an asthma and anasarca. He had taken several medicines
by the direction of a very judicious apothecary, but not getting
relief as he had been accustomed to do in former years, he came
under my direction. For the space of a month I tried to relieve
him by fixed alkaly, seneka, Dover’s powder, gum ammoniac,
squill, &c. but without effect. 1 then directed Infusion of Digi-
talis, which soon increased the flow of urine without exciting nau-
sea, and in a few days removed all his complaints.
355
The Foxglove
(p. 63) 1782
Case LXXXIII
'January 23d. Mr. Q , Aet. 74. A stone in his bladder
for many years; dropsical for the last three months. Had taken
at different times soap with squill and gum ammoniac; soap lees;
chrystals of tartar, oil of juniper, seneka, jallap, &c. but the drop-
sical symptoms still increased, and the dysuria from the stone
became very urgent. I now directed a dram of the Fol. Digit,
siccat. in a half pint infusion, half an ounce to be given every
six hours. This presently relieved the dysuria, and soon removed
the dropsy, without any disturbance to his system.
Case LXXXIV
January 27th. Mr. D , Aet. 86. The debility of age and
dropsical legs had long oppressed him. A few weeks before his
death his breathing became very short, he could not lie down in
bed, and his urine was small in quantity. A wine glass of a weak
Infusion of Digitalis, warmed with aromatics, was ordered to be
taken twice a day. It afforded a temporary relief, but he did
not long survive.
Case LXXXV
January 28th. Mr. D , Aet. 35. A publican and a hard
drinker. Ascites, anasarca, diseased (p. 64) viscera, and slight
attacks of haemoptoe. A dram of Fol. Digital, sicc. in a half
pint infusion, of which one ounce was given night and morning,
proved diuretic and removed his dropsy. He then took medi-
cines calculated to relieve his other complaints. The dropsy did
not return during my attendance upon him, which was three or
four weeks. A quack then undertook to cure him with blue
vitriol vomits, but as I am informed, he presently sunk under
that rough treatment.
Case LXXXV I
January 29th. Mrs. O , of D , Aet. 53. A constant
and distressing palpitation of her heart, with great debility.
Medical Classics
35 6
From a degree of anasarca in her legs I was led to suspect effusion
in the Pericardium, and therefore directed Digitalis, but it pro-
duced no benefit. She then took various other medicines with
the same -want of success, and about ten months afterwards
died suddenly.
Case LXXXVII
January 31st. Mr. T , of A , Aet. 81. Great diffi-
culty of breathing, so that he had not lain in bed for the last
six weeks, and some swelling in his legs. These complaints were
subsequent to a very severe cold, and he had still a troublesome
cough. He told me that at his age he did not look for a cure,
but should be glad of relief, if it could be obtained without taking
much medicine. I directed an Infusion of Digitalis, a dram to
eight ounces, (p. 65) one spoonful to be taken every morning,
and two at night. He only took this quantity; for in four days
he could lie down, and soon afterwards quitted his chamber. In
a month he had a return of his complaints, and was relieved as
before.
Case LXXXVII I
January 31st. Mrs> J , of S , Aet. 67. A lusty woman,
of a florid complexion, large belly, and very thick legs. She
had been kept alive for some years by the discharge from ulcers
in her legs; but the sores now put on a very disagreeable livid
appearance, her belly grew still larger, her breath short, her
pulse feeble, and she could not take nourishment. Several
medicines having been given in vain, the Digitalis was tried, but
with no better effect; and in about a month she died.
Case LXXXIX
February 2d. Mr. B , Aet. 73. An universal dropsy.
He took various medicines, and Digitalis in small doses, but with-
out any good effect.
Case XC
February 24th. Master M , of W , Aet. 10. An
epilepsy of some years continuance, which had never been inter-
rupted by any of the various methods tried for his relief. The
The Foxglove 357
Digitalis was given for a few days, but as he lived at a distance,
so that I could not attend to its effects, he only took one (p. 66)
half pint infusion, which made no alteration in his complaint
Case XCI
March 6th. Mr. H , Aet. 62. A very hard drinker, and
had twice had attacks of apoplexy. He had now an ascites, was
anasarcous, and had every appearance of a diseased liver. Small
doses of calomel, Dover’s powder, infusum amarum, and sal
sodae palliated his symptoms for a while; these failing; blisters,
squills, and cordials were given without effect. A weak Infu-
sion of Digitalis, well aromatised, was then directed to be given
in small doses. It rather seemed to check than to increase the
secretion of urine, and soon produced sickness. Failing in its
usual effect, the medicine was no longer continued; but every
thing that was tried proved equally inefficacious, and he did not
long survive.
Case XCII
May 10th. Mrs. P , Aet. 40. Spasmodic asthma of many
years continuance, which had frequently been relieved by am-
moniacum, squills, &c. but these now failing in their wonted
effects, an Infus. of Fol. Digitalis was tried, but it seemed rather
to increase than relieve her symptoms.
Case XCIII
May 22d. Mr. O , of B •, Aet. 61. A very large man,
and a free liver; after an attack of (p. 67) hemiplegia early in
the spring, from which he only partially recovered, became drop-
sical. The dropsy occupied both legs and thighs, and the arm
of the affected side. I directed an Infusion of Digitalis in small
doses, so as not to affect his stomach. The swellings gradually
subsided, and in the course of the summer he recovered perfectly
from the palsy.
Case XCIV
July 5th. Mr. C , of W , Aet. 28. Had drank very
freely both of ale and spirits; and in consequence had an ascites,
Medical Classics
358
very large legs, and great fulness about the stomach. He was
ordered to take the Infusion of Digitalis night and morning for a
few days, and then to keep his bowels open with chrystals of
tartar. The first half pint of infusion relieved him greatly;
after an interval of a fortnight it was repeated, and he got well
without any other medicine, only continuing the chrystals of
tartar occasionally. I forgot to mention that this gentleman,
before I saw him, had been for two months under the care of a
very celebrated physician, by whose direction he had taken mer-
curials, bitters, squills, alkaline salts, and other things, but
without much advantage.
Case XCV
March 6th. Mrs. W , Aet. 36. In the last stage of a
pulmonary consumption, took the Infus. Digitalis, but without
any advantage.
(p. 68) Case XCVI
August 20th. Mr. P , Aet. 43. In the year 1781 he had a
severe peripneumony, from which he recovered with difficulty.
At the date of this, when he first consulted me, the symptoms
of hydro-thorax were pretty obvious. I directed a purge, and
then the Infusum Digitalis, three drams to half a pint, one ounce
to be taken every four hours. It made him sick, and occasioned a
copious discharge of urine. His complaints immediately van-
ished, and he remains in perfect health.
Case CVII
September 24th. Mrs. R , of B , Aet. 35, the mother
of many children. After her last lying in, three months ago,
had that kind of swelling in one of her legs which is mentioned
at No. VIII, XXVI, and XXXI. A considerable degree of
swelling still remained; the limb was heavy to her feeling, and
not devoid of pain. I directed a bolus of five grains of Pulv
Digitalis, and twenty-five of crude quicksilver rubbed down,
with conserve of cynosbat. to be taken at bed-time, and after-
The Foxglove 359
wards an Infusion of red bark and Fol. Digitalis to be taken
twice a day. There was half an ounce of bark and half a dram
of the leaves in a pint infusion: the dose two ounces.
The leg soon began to mend, and two pints of the infusion
finished the cure.
(p. 69) Case XCVIII
September 25th. Mr. R , Aet. 60. Complained to me of
a sickness after eating, and for some weeks past he had thrown
up all his food, soon after he had swallowed it. He had taken
various medicines, but found benefit from none, and had tried
various kinds of diet. He was now very thin and weak, but had
a good appetite. As several very probable methods had been
prescribed, and as the usual symptoms of organic disease were
absent, I determined to give him a spoonful of the Infusion of
Digitalis twice a day; made by digesting two drams of the dried
leaves in half a pint of cinnamon water. From the time he began
to take this medicine he suffered no return of his complaint,
and soon recovered his flesh and his strength.
It should be observed, that I had frequently seen the Digitalis
remove sickness, though prescribed for very different complaints.
Case XCIX
September 30th. Mrs. A , Aet. 38. Hydro-thorax and
anasarca. Her chest was very considerably deformed. One
half pint of the Digitalis Infusion entirely cured her.
(p. 70) Case C
September 30th. Mr. R , of W , Aet. 47. Hydro-
thorax and anasarca. An Infusion of Digitalis was directed,
and after the expected effects from that should take place, sixty
drops of tincture of cantharides twice a day. As he was costive
pills of aloes and steel were ordered to be taken occasionally.
This plan succeeded perfectly. About a month afterwards he
had some rheumatic affections, which "were removed by guiacum.
360 Medical Classics
Case Cl
October 2d. Mrs. R , Aet. 60. Diseased viscera; ascites
and anasarca. Had taken various deobstruent and diuretic
medicines to little purpose. The Digitalis brought on a nausea
and languor, but had no effect on the kidneys.
Case CII
October 12th. Mr. R > Aet. 41. A publican, and a hard
drinker. His legs and belly greatly swollen; appetite gone,
countenance yellow, breath very short, and cough troublesome.
After a vomit I gave him calomel, saline draughts, steel and
bitters, &c. He had taken the more usual diuretics before I
saw him. As the dropsical symptoms increased, I changed his
medicines for pills made of (p. 71) soap, containing two grains
of Pulv. fol. Digital, in each dose, and, as he was costive, two
grains of jallap. He took them twice a day, and in a week was
free from every appearance of dropsy. The jaundice soon after-
wards vanished, and tonics restored him to perfect health.
Case CIII
October 12th. Mr. B , Aet. 39. Kept a public house,
drank very freely, and became dropsical; he complained also of
rheumatic pains. I directed Infusion of Digitalis, half an ounce
twice a day. In eight days the swellings in his legs and the ful-
ness about his stomach disappeared. His rheumatic affections
were cured by the usual methods.
Case CIV
October 22d. Master B , Aet. 3. Ascites and universal
anasarca. Half a grain of Fol. Digital, siccat. given every six
hours, produced no effect; probably the medicine was wasted
in giving. An infusion of the dried leaf was then tried, a dram
to four ounces, two tea spoonfuls for a dose; this soon increased
the flow of urine to a very great degree, and he got perfectly
well.
3^1
The Foxglove
Case CV
October 30th. Mr. G , of W , Aet. 88. The gentleman
mentioned in No. XLVII. His complaints and manner of living
the same as there (p. 72) mentioned. I ordered an Infusion of
the Digitalis, a dram and half to half a pint; one ounce to be
taken twice a day; which cured him in a short time.
On March the 23d, 1784, he sent for me again. His complaints
were the same, but he was much more feeble. On this account I
directed a dram of the Fol. Digitalis to be infused for a night in
four ounces of spirituous cinnamon water, a spoonful to be taken
every night. This had not a sufficient effect; therefore, on the
22d of April , I ordered the infusion prescribed two years before,
which soon removed his complaints.
He died soon afterwards, fairly worn out, in his ninetieth year.
Case CVI
November 2d. Mr. S , of B h , Aet. 61. Hydro-
thorax and swelled legs. Squills were given for a week in very
full doses, and other modes of relief attempted; but his breathing
became so bad, his countenance so livid, his pulse so feeble,
and his extremities so cold, that- 1 was apprehensive upon my
second visit that he had not twenty-four hours to live. In this
situation I gave him the Infusum Digitalis stronger than usual,
viz. two drams to eight ounces. Finding himself relieved by
this, he continued to take it, contrary to the directions given,
after the diuretic effects had appeared.
(p. 73) The sickness which followed was truly alarming; it
continued at intervals for many days, his pulse sunk down to
forty in a minute, every object appeared green to his eyes, and
between the exertions of reaching he lay in a state approaching
to syncope. The strongest cordials, volatiles, and repeated blis-
ters barely supported him. At length, however, he did begin
to emerge out of the extreme danger into which his folly had
plunged him; and by generous living and tonics, in about two
months he came to enjoy a perfect state of health.
362 Medical Classics
Case evil
November 19th. Master S , Aet. 8. Ascites and anasarca.
A dram of Fol. Digitalis in a six ounce infusion, given in doses
of a spoonful, effected a perfect cure, without producing nausea.
* 7*3
The reader will perhaps remark, that from the middle of Jan-
uary to the first of May , not a single case occurs, and that the
amount of cases is likewise less than in the preceding or ensuing
years; to prevent erroneous conjectures or conclusions, it may be
expedient to mention, that the ill state of my own health obliged
me to retire from business for some time in the spring of the year,
and that I did not perfectly recover until the following summer.
(p. 74) Case CVIII
January 15th. Mrs. G , Aet. 57. A very fat woman;
has been dropsical since November last; with symptoms of dis-
eased viscera. Various remedies having been taken without
effect, an Infusion of Digitalis was directed twice a day, with a
view to palliate the more urgent symptoms. She took it four
days without relief, and as her recovery seemed impossible it was
urged no farther.
Case CIX
May 1st. Mrs. D , Aet. 7 1. A thin woman, with very
large anasarcous legs and thighs; no appetite and general debility.
After a month's trial of cordials and diuretics of different kinds,
the surgeon who had scarified her legs apprehended they would
mortify; she had very great pain in them, they were very red
and black by places, and extremely tense. It was evident that
unless the tension could be removed, gangrene must soon ensue.
I therefore gave her Infusum Digitalis, which increased the secre-
tion of urine by the following evening, so that the great tension
began to abate, and together with it the pain and inflammation.
She was so feeble that I dared not urge the medicine further,
but she occasionally took it at intervals until the time of her
death, which happened a few weeks afterwards.
The Foxglove 363
(p. 75) Case CX
May 1 8th. I was desired to prescribe for May Bowen, a poor
girl at Hagley. Her disease appeared to me to be an ovarium
dropsy. In other respects she was in perfect health. I directed
the Digitalis to be given, and gradually pushed so as to affect
her very considerably. It was done; but the patient still carries
her big belly, and is otherwise very well.
Case CXI
May 25th. Mr. G , Aet. 28. In the last stage of a pul-
monary consumption of the scrophulous kind, took an Infusion
of Digitalis, but without any advantage.
Case CXII
May ^ 1st. Mr. H , Aet. 27. In the last state of a phthisis
pulmonalis became dropsical. He took half a pint of the In-
fusum Digitalis in six days, but without any sensible effect.
Case CXIII
June 3d. Master B , of D , Aet. 6. With an uni-
versal anasarca, had an extremely troublesome cough. An
opiate was given to quiet the cough at night, and 2 tea spoonfuls
of Infus. Digit, were ordered every six hours. The dropsy was
presently removed; but the cough continued, his (p. 76) flesh
wasted, his strength failed, and some weeks afterwards he died
tabid.
Case CXIV
June 19th. Mrs. L , Aet. 28. A dropsy in the last stage
of a phthisis. Infusum Digitalis was tried to no purpose.
Case CXV
June 20th. Mrs. H , Aet. 46. A very fat, short woman,
had suffered severely through the last winter and spring from
what had been called asthma; but for some time past an universal
anasarca prevailed, and she had not lain down for several weeks.
After trying vitriolic acid, tincture of cantharides, squills, etc.
364 Medical Classics
without advantage, she took half a pint of Infus. Digitalis in
three days. In a week afterwards the dropsical symptoms dis-
appeared, her breath became easy, her appetite returned, and
she recovered perfect health. The infusion neither occasioned
sickness nor purging.
Case CXVI
June 24th. Mrs. B , Aet. 40. A puerperal fever, and
swelled legs and thighs. The fever not yielding to the usual
practice, I directed an Infusion of Fol. Digitalis. It proved
diuretic; the swellings subsided, but the fever continued, and
a few days afterwards a diarrhoea coming on, she died.
(p. 77) Case CXVII
July 22d. Mr. F , Aet. 48. A strong man, of a florid
complexion, in consequence of intemperance became dropsical,
v/ith symptoms of diseased viscera, great dyspnoea, a very
troublesome cough, and total loss of appetite. He took mild
mercurials, pills of soap, rhubarb, and tartar of vitriol, with
soluble tartar and dulcified spirits of nitre in barley water. After
a reasonable trial of this plant; he took squill every six hours, and a
solution of assafetida and gum ammoniac, to ease his breathing:
finding no relief, I gave him chrystals of tartar with ginger; but
,S r . < ! n ? a ’ n ^ n S health and strength daily declined, and he was not
at all benefited by the medicines. I was averse to the use of
. 1 S J * :a Is m *-his case, judging from what I had seen in similar
instances of tense fibre, that it would not act as a diuretic. I
ere ore once more directed squill, with decoction of seneka
an sa so ae, but it was inefficacious. His strength being much
o en ow n, then ordered gum ammoniac, with small doses
o opuam and m f usum amarum, cont ; nu ; ng the squiU at i nterva i s .
am*** A V/aS U ^ ed to &* ve t ^ le Digitalis, and considering the
nn inn- es ^? rat ^ 5 a S re ed to do it. The event was as I expected;
c ™\ m U T C t0 ° k pkce; and the medicine being still
its sedativ Se k 55 ame s ^ ow » an d he apparently sunk under
had the Di Lit r^’ 1 WaS ne ’ t h er purged nor vomited; and
had the Digitalis either been omitted (p. 78) altogether.
or sus-
The Foxglove 365
pended upon its first effects upon the pulse being observed, he
might perhaps have existed a week longer.
Case CXVIII
July 26th. Mr. W , of W , Aet. 47. Phthisis pul-
monalis, jaundice, ascites, and swelled legs. As it was probable
that the only relief I could give in a case so circumstanced,
would be by carrying off the effused fluids. I tried squill and
fixed alkaly; and these failing, I ordered the Infusum Digitalis.
This had the desired effect, and, I believe, prolonged his life a
few weeks.
Case CXIX
August 15th. Mrs. C , Aet. 60. Ascites, anasarca, dis-
eased viscera, paucity of urine, and total loss of appetite. These
complaints had heretofore existed repeatedly, and had been
removed by deobstruent and diuretic medicines; but in this
attack the symptoms were suffered to exist a longer time and in a
greater degree, before assistance was sought for. The remedies
that used to relieve her were now exhibited to no purpose. Mild
mercurials, soap, rhubarb, and squill were tried; but she grew
rapidly worse. Saline draughts with acetum scilliticum seemed
for a few days to check the progress of her complaint, but they
soon lost their effect, and diarrhoea ensued upon every attempt
to increase the frequency of the dose. Draughts with Infus.
Digital, were then directed to be taken twice (p. 79) a day. The
effect was a powerful action on the kidneys, and a reduction of
the swellings, but without sickness. A degree of appetite re-
turned, but still the tendency to diarrhoea existed, and kept her
weak. Tonic medicines were then tried, but without advantage,
and in a month it was necessary to have recourse to the Digitalis
again. It was directed in a half pint mixture; an ounce to be
taken thrice in twenty-four hours. On the 2d day, finding her
symptoms very much relieved, she took in the absence of her
nurse, nearly a double dose of the medicine. The consequence
was great sickness, languor continuing for several days, and al-
most a total stop to the secretion of urine, from the time the sick-
ness commenced.
364 Medical Classics
without advantage, she took half a pint of Infus. Digitalis in
three days. In a week afterwards the dropsical symptoms dis-
appeared, her breath became easy, her appetite returned, and
she recovered perfect health. The infusion neither occasioned
sickness nor purging.
Case CXVI
June 24th. Mrs. B , Aet. 40. A puerperal fever, and
swelled legs and thighs. The fever not yielding to the usual
practice, I directed an Infusion of Fol. Digitalis. It proved
diuretic; the swellings subsided, but the fever continued, and
a few days afterwards a diarrhoea coming on, she died.
(p. 77) Case CXVII
July 22d. Mr. F , Aet. 48. A strong man, of a florid
complexion, in consequence of intemperance became dropsical,
with symptoms of diseased viscera, great dyspnoea, a very
troublesome cough, and total loss of appetite. He took mild
mercurials, pills of soap, rhubarb, and tartar of vitriol, with
soluble tartar and dulcified spirits of nitre in barley water. After
a reasonable trial of this planlj he took squill every six hours, and a
solution of assafetida and gum ammoniac, to ease his breathing:
finding no relief, I gave him chrystals of tartar with ginger; but
his remaining health and strength daily declined, and he was not
at ail benefited by the medicines. I was averse to the use of
Digitalis in this case, judging from what I had seen in similar
instances of tense fibre, that it would not act as a diuretic. I
t erefore once more directed squill, with decoction of seneka
and sal sodae; but it was inefficacious. His strength being much
ro ^en down, I then ordered gum ammoniac, with small doses
o opium, and infusum amarum, continuing the squill at intervals.
t engt was urged to give the Digitalis, and considering the
case as esperate, I agreed to do it. The event was as I expected;
no increase in the urine took place; and the medicine being still
contmue^ , is pulse became slow, and he apparently sunk under
hi A at ^ e was ne ither purged nor vomited; and
ad the Digitalis either been omitted (p. 78) altogether, or sus-
The Foxglove 365
pended upon its first effects upon the pulse being observed, he
might perhaps have existed a week longer.
Case CXVIII
July 26th. Mr. W , of W , Aet. 47. Phthisis pul-
monalis, jaundice, ascites, and swelled legs. As it was probable
that the only relief I could give in a case so circumstanced,
would be by carrying off the effused fluids. I tried squill and
fixed alkaly; and these failing, I ordered the Infusum Digitalis.
This had the desired effect, and, I believe, prolonged his life a
few weeks.
Case CXIX
August 15th. Mrs. C , Aet. 60. Ascites, anasarca, dis-
eased viscera, paucity of urine, and total loss of appetite. These
complaints had heretofore existed repeatedly, and had been
removed by deobstruent and diuretic medicines; but in this
attack the symptoms were suffered to exist a longer time and in a
greater degree, before assistance was sought for. The remedies
that used to relieve her were now exhibited to no purpose. Mild
mercurials, soap, rhubarb, and squill were tried; but she grew
rapidly worse. Saline draughts with acetum scilliticum seemed
for a few days to check the progress of her complaint, but they
soon lost their effect, and diarrhoea ensued upon every attempt
to increase the frequency of the dose. Draughts with Infus.
Digital, were then directed to be taken twice (p. 79) a day. The
effect was a powerful action on the kidneys, and a reduction of
the swellings, but without sickness. A degree of appetite re-
turned, but still the tendency to diarrhoea existed, and kept her
weak. Tonic medicines were then tried, but without advantage,
and in a month it was necessary to have recourse to the Digitalis
again. It was directed in a half pint mixture; an ounce to be
taken thrice in twenty-four hours. On the 2d day, finding her
symptoms very much relieved, she took in the absence of her
nurse, nearly a double dose of the medicine. The consequence
was great sickness, languor continuing for several days, and al-
most a total stop to the secretion of urine, from the time the sick-
ness commenced.
Medical Classics
366
The case now became totally unmanageable in my hands, and,
after a fortnight, I was dismissed, and another physician called
in: but she did not long survive.
This was not the first, nor the last instance, in which I have
seen too large a dose of the medicine, defeat the very purpose for
which it was directed.
Case CXX
August 2 id. Mrs. S , Aet. 36. Extreme faintiness; ana-
sarcous legs and thighs; great difficulty of breathing, troublesome
cough, frequent chilly fits succeeded by hot ones; night sweats,
and a tendency to diarrhoea. Apprehensive that the (p. 80)
more urgent symptoms were caused by water in the lungs, I
directed an Infusion of Digitalis, with an ounce of diacodium to
the half pint to prevent it purging, a wine glass full to be taken
every night at bed-time, and a mixture with confect, cardiac,
and pulv. ipecac, to be given in small doses after every loose stool.
On the fourth day she was better in all respects; had made a
large quantity of water and did not purge. In a few days more
she lost all her complaints, except the cough, which gradually
left her, without any further assistance.
I was agreeably deceived in the event of this case, for I ex-
pected after the water was removed, to have had a phthisis to
contend with.
Case CXXI
August 25th. T W , Esq; Aet. 50. A free liver,
diseased viscera, belly very tense, and much swollen; fluctuation
perceptible, but the swelling circumscribed; pulse 132. This
gentleman was under the care of my very worthy friend Dr. Ash,
^ aving tried various modes of cure to no purpose, asked me
1 , t . 0u §ht the Digitalis would answer in this case. I replied
wou ld not, for I had never seen it effectual where the
swe g appeared very tense and circumscribed. It was tried
owever, ut did not lessen the swelling. I mention this case,
intro uce t e above remark, and also (p. 81) to point out the
great effect the Digitalis has upon the action of the heart; for
The Foxglove 367
the pulse came down to 96. He was afterwards tapped, and
continued, for some time under our joint attendance, but the
pulse never became quicker, nor did the swelling return.
Case CXXII
September 7th. Mr. L , Aet. 43. After several severe
attacks of ill formed gout, attended for some time past with
jaundice and other symptoms of diseased viscera, the conse-
quences of intemperate living, was sent to Buxton; from whence
he returned in three weeks with ascites and anasarca. Under
this complicated load of disease, I prescribed repeatedly without
advantage, and at length gave him the Digitalis, which carried
off the more obvious symptoms of dropsy; but the jaundice,
loss of appetite, diseased viscera, &c. rendered his recovery im-
possible.
1784
Case CXXIII
February 12th. Mrs. C , Aet. 54. A strong short woman
of a florid complexion; complained of great fullness across the
region of the stomach; short breath, a troublesome cough, loss of
appetite, paucity of urine; and had a brownish yellow tinge on
her skin and in her eyes. She dated these complaints from a
fall she had through a trap door about the beginning of winter.
From the beginning of January to this time, she had been re-
peatedly let (p. 82) blood, had taken calomel purges with jallap;
pills of soap, rhubarb and calomel; saline julep with acet. scillit.
nitrous decoction, garlic, mercury rubbed down, infus. amarum
purg. &c. After the failure of medicines so powerful, and seem-
ingly so well adapted, and during the use of which all the symp-
toms continued to increase, it was evident that a favourable
event could not be expected. However, I tried the infusum
Digitalis, but it did nothing. I then gave her pills of quicksilver,
soap and squill, with decoction of dandelion, and after some time,
chrystals of tartar with ginger. Nothing succeeded to our wishes,
and the increase of orthopnoea compelled me occasionally to
relieve her by drastic purges, but these diminished her strength.
368 Medical Classics
more in proportion than they relieved her symptoms. Tincture
of cantharides, sal diureticus and various other means were
occasionally tried, but with very little effect, and she died towards
the end of March.
Case CXXIV
March 31st. Miss W , Aet. 60. Had been subject to
peripneumonic affections in the winter. She had now total loss
of appetite, very great debility, difficult breathing; much cough,
a considerable degree of expectoration, and a paucity of urine.
She had been blooded, taken soap, assaf. and squill, afterwards
assaf. and ammon. with acet. scillit.: but all her complaints in-
creasing, a blister was applied to her back, and the Digitalis
infusion directed to be taken every night. The effect was an
increased (p. 83) secretion of urine, a considerable relief to her
breath and some return of appetite; but soon afterwards she be-
came hectic, spat purulent matter, and died in a few weeks.
Case CXXV
April iath. Mrs. H , of L , Aet. 61. In December
last this Lady, then upon a visit in London, was attacked with
severe symptoms of peripneumony. She was treated as an
asthmatic patient, but finding no relief, she made an effort to
return to her home to die. In her way through this place, the
latter end of December, I was desired to see her. By repeated
bleedings, blisters, and other usual methods, she was so far re-
lieved, that she wished to remain under my care. After a while
she began to spit matter and became hectic. With great diffi-
culty she was kept alive during the discharge of the abscess,
and about the end of March she had swelled legs, and unequiv-
ocal symptoms of dropsy in the chest. Other diuretics failing,
° n t i, e J I2t ^ 1 April I was induced to give her the Digitalis in
sma oses. The relief was great and effectual. After an in-
terva o fifteen days, 9 ome swellings still remaining in the legs,
I repeated the medicine, and with such good effect, that she lost
, Com P a ’ nts , got a keen appetite, recovered her strength,
and about the end of May undertook a journey of fifty miles to
er own ome, where she still remains in perfect health.
The Foxglove 369
(p. 84) Case CXXVI
April 17th. Mr. F , Aet. 59. A very fat man, and a free
liver; had long been subject to what was called asthma, partic-
ularly in the winter. For some weeks past his legs swelled, he
had great sense of fullness across his stomach; a severe cough;
total loss of appetite, thirst great, urine sparing, his breath so
difficult that he had not lain down in bed for several nights.
Calomel, gum ammoniac, tincture of cantharides, &c. having
been given in vain, I ordered two grains of pulv. fol. Digitalis
made into pills, with aromatic species and syrup, to be given
every night. On the third day his urine was less turbid; on the
fourth considerably increased in quantity, and in ten days more
he was free from all complaints, and has since had no relapse.
Case CXXVII
May 7th. Miss K , Aet. 8. After a long continued ague,
became hectic and dropsical. Her belly was very large, and she
had a total loss of appetite. Half a grain of fol. Digital, pulv.
with 2 gr. of mere, alcalis. were ordered night and morning, and
an infusion of bark and rhubarb with steel wine to be given in
the day time. Her belly began to subside in a few days, and
she was soon restored to health. Two other children in the fam-
ily, affected nearly in the same way, had died, from the parents
being persuaded that an ague in the spring (p. 85) was healthful
and should not be stopped. — I know not how far the recovery in
this case may be attributed to the Digitalis, but the child was so
near dying that I dared not trust to any less efficacious diuretic.
Case CXXVIII
June 13th. Mr. C , Aet. 45. A fat man, had formerly
drunk hard, but not latterly: last March began to complain of
difficult breathing, swelled legs, full belly, but without fluctua-
tion, great thirst, no appetite; urine thick and foul; complection
brownish yellow. Mercurial medicines, diuretics of different
kinds, and bitters, had been trying for the last three months,
but with little advantage. I directed two grains of the fol.
Digital, in powder to be taken every night, and infus. amar. with
tinct. sacr. twice a day. In three days the quantity of his urine
Medical Classics
37 °
increased, in ten or twelve days all his symptoms disappeared,
and he has had no relapse.
Case CXXIX
June 17th. Mr. N , of W , Aet. 54. A large man, of
a pale complexion; had been subject to severe fits of asthma for
some years, but now worse than usual. The intermitting pulse,
the great disturbance from change of posture, and the swelled
legs induced me to conclude that the exacerbation of his old com-
plaint was occasioned by serous effusion. I directed pills with a
grain and half of the (p. 86) pulv. Digital, to be taken every
night, and as he was costive, jallap made a part of the composi-
tion. He was also directed to take mustardseed every morning
and a solution of assafetida twice in the day. The effect of this
plan was perfectly to our wishes, and in a short time he recovered
his usual health. About half a year afterwards he died apo-
plectic.
Case CXXX
Mary B . A young unmarried woman. Her disease
appeared to me a dropsy of the right ovarium. She took an
infusion of Digitalis, but, as I expected with no good effect. She
is still, I am informed, nearly in the same state.
Case CXXXI
. Mth. Mrs. A , of C , Act. 56. After a series of
indispositions for several years* became dropsical; and had long
been confined to her chamber* unable to lie down or to walk.
She was so feeble, her legs so much swelled* her breath so short*
and the symptoms of diseased viscera so strong, that I dared not
to entertain hopes of a cure; but wishing to relieve her more ur-
gent symptoms* directed quicksilver rubbed down and sol.
igita . pulv. to be made into pills: the dose* containing two
grams o t e latter* to be given night and morning. She was
a so or ere to take a draught with a dram of aether twice a
aay* and to have scapulary issues. Her breath was so much re-
5 P* " that she was able soon afterwards to come down
The Foxglove 371
stairs; but her constitution was too much broken to admit of a
recovery.
Case CXXXII
July 1 6th. Mr. B , of W , Aet. 31. After a tertian
ague of 12 months continuation, suffered great indisposition for
10 months more. He chiefly complained of great straitness and
pain in the hypochondriac region, very short breath, swelled
legs, want of appetite. He had been under the care of some very
sensible practitioners, but his complaints increased, and he deter-
mined to come to Birmingham. I found him supported upright
in his chair, by pillows, every attempt to lean back or stoop
forward giving him the sensation of instantaneous suffocation.
He said he had not been in bed for many weeks. His counte-
nance was sunk and pale; his lips livid; his belly, thighs and legs
very greatly swollen; hands and feet cold, the nails almost black,
pulse 160 tremulous beats in a minute, but the pulsation in the
carotid arteries was such as to be visible to the eye, and to shake
his head so that he could not hold it still. His thirst was very
great, his urine small in quantity, and he was disposed to purge.
I immediately ordered a spoonful of the infusum Digitalis every
six hours, with a small quantity of laudanum, to prevent its
running off by stool, and decoction of leontodon taraxacum to
allay his thirst. The next day he began to make water freely,
and could (p. 88) allow of being put into bed, but was raised high
with pillows. Omit the infusion. That night he parted with
six quarts of water, and the next night could lie down and slept
comfortably. July 21st. he took a mild mercurial bolus. On
the 25th. the diuretic effects of the Digitalis having nearly ceased,
he was ordered to take three grains of the pulv. Digital, night and
morning, for five days, and a draught with half an ounce of vin.
chalyb. twice a day. August 1 5th. He took a purge of calomel
and jallap, and some swelling still remaining in his legs, the Digi-
talis infusion was repeated. The water having been thus entirely
evacuated, he was ordered saline draughts with acetum scilliticum
and pills of salt of steel and extract of gentian. About a month
after this, he returned home perfectly well.
372 Medical Classics
Case CXXXIII
July 28th. Mr. A of W , Aet. 29, became dropsical
towards the close of a pulmonary consumption. He was ordered
12 grains of pulv. sol. cicutae and 1 of Digitalis twice a day. No
remarkable effect took place.
Case CXXXIV
July 31. Mr. M , Aet. 37. Hydro thorax. A single
grain of sol. Digital, pulv. taken every night for three weeks
cured him. The medicine never made him sick, but increased
his urine, which became clear; whereas before it had been high
coloured and turbid.
(p. 89) Case cx: XXV
August 6th. Mr. C of B , Aet. 42. Asthma and’
anasarca, the consequence of free living. He had been for some
time under the care of an eminent physician of this place, but
his complaints proving unusually obstinate, he consulted me. I
directed an infusion of Digitalis to be taken every night, and a
mixture with squill and tincture of cantharides twice a day. In
about a week he became better, and continued daily mending.
He has since enjoyed perfect health, having quitted a line of
business which exposed him to drink too much.
Case CXXXVI
August 6th. Mr. M of C , Aet. 44. Ascites and ana-
sarca, preceded by symptoms of the epileptic kind. He was
or ere to take two grains of pulv. Digitalis every morning, and
t ree every night; likewise a saline draught with syrup of squills,
every ay at noon. His complaints soon yielded to this treat-
ment, but m the month of November following he relapsed, and
again as e my advice. . The digitalis alone was now prescribed,
r • C prwed as efficacious as in the first trial. He then took
n £ ^ f wice a day, and vitriolic acid night and morning, and
now enjoys good health. 6
sol “ w &s prescribed, he had taken jallap purges,
soluble tartar, salt of steel, vitriol of copper, &c.
The Foxglove 373
(p. 90) Case CXXXVII
August 10th. Mrs. W , Aet. 55. An anasarcous leg,
and sciatica; full habit. After bleeding and a purge, a blister
was applied in the manner recommended by Cotunnius; and two
grains of sol. Digital, with fifteen of sol. cicutae were directed
to be taken night and morning. The medicine acted only as a
diuretic; the pain and swelling of the limb gradually abated;
and I have not heard of any return.
I must here bear witness to the efficacy of Cotunnius’s method
of blistering in the sciatica, having used it in a great number of
cases, and generally with success.
Case CXXXVIII
August 1 6th. Mrs. A of S , Aet. 78. About the mid-
dle of Summer began to complain of short breath, great debility,
and loss of appetite. At this time there were evident marks of
effusion in the thorax, and some swellings in the legs. The
advanced age, the weakness, and other circumstances of this
patient, precluded every idea of her recovery; but something
was to be attempted. Squills and other remedies had been
tried; I therefore directed pills with two or three grains of the
pulv. Digitalis to be taken every night for six nights, and a saline
draught with forty drops of acetum scillit. twice in the day.
She took but few of the draughts, seldom (p. 91) more than half
one at a time, for they purged her, and she disliked them. The
pills she took regularly, and with the happiest effect, for she could
lie down, her breath was very much relieved, and a degree of
appetite returned. Sept. 4th, some return of her symptoms de-
manded the further use of diuretics. I was afraid to push the
Digitalis in so hazardous a subject, and therefore directed tinct.
amara with tinct. canthar. and pills of squill, seneka, salt of tartar
and gum ammoniac. These medicines did not at all check the
progress of the disease, and on the 26th it became necessary to
give the Digitalis again. The pills were therefore repeated as
before, and infus. amarum with fixed alkaly ordered to be taken
twice a day. The event was as favorable as before; and from
this time she had no considerable return of dropsy, but languished
374 Medical Classics
under various nameless symptoms, until the middle or end of
November.
Case CXXXIX
Aug. 1 6th. Mrs. P of S , Aet. 50. For a particular
account of this patient, see Mr. Yonge’s second Case.
Case CXL
Sept. 20th. B B , Esq. A true spasmodic asthma
of many years continuance. After every method of relief had
failed; both under my management, and also under the direction
of several of the ablest physicians of this kingdom; I was induced
to (p. 92) give him an infusion of the Digitalis. It was continued
until nausea came on but procured no relief.
Case CXLI
October 5th. Mr. R , Aet. 43. {'The patient mentioned
at No. 102.) He had pursued his former mode of life, and had
now a return of his complaints, with evident marks of diseased
viscera. His belly not very large, but uncommonly tense. From
this circumstance I did not expect the Digitalis to succeed, and
therefore tried for some time to relieve him by the saline julep,
with acet scillitic. jallap, mercury, syrup of squill, with aq.
cinnam. decoction of Dandelion, &c.; but these being adminis-
tered without advantage, I was driven to the Digitalis. As he
was very weak and much emaciated, I only gave two grains night
and morning for five days. As no increase of urine took place,
I used alkaline salt with tinct. cantharieds:— This proving equally
unsuccessful, on the 18th, I directed two ounces of the infusum
igi L a is night and morning. This was continued until nausea
took place, but the kidney secretion was not increased. Squill
fi ,lt |-l °?i- U i n5 ^ eo ^ stru f nts different kinds, sublimate solution,
■\ \ ^ ^ to ^ acco infusion, were now successively tried, but
t e same want of success. The fullness of his belly made it
S*TT. t0 ta P him, and by repeating this operation he con-
tinued alive to the end of the year.
375
The Foxglove
(p. 93) Case CXLII
October 19th. Mrs. R , of B— — , Aet. 47. Supposed
Asthma, of eighteen months duration. She had kept her room
for four months, and could not lie down without great disturb-
ance; was very thin, and had totally lost all inclincation for food.
She was directed to take two gr. of pulv. sol. Digital, night and
morning for five days, and infusum amarum, at the hours of
eleven and five. In the course of a week she was much relieved,
and could remain in bed all night. After a few days interval
she took the Digitalis for five days more, and was soon after that
well enough to come down stairs and conduct her family affairs.
In April 1785, she had a slight return, but not such as to con-
fine her to her chamber. She experienced the same relief from
the same medicine, but continuing it for seven days without
interruption, it excited nausea.
Case CXLIII
October 28th. Mr. A , subject to nephritis calculosa:
After an attack of that kind, had still a troublesome sense of
weight about his loins, now and then rising to pain, and a degree
of dysuria, together with a want of appetite. These symptoms
not readily yielding to the usual methods of treatment, I directed
an infusion of Digitalis. The fourth dose (p. 94) caused a copi-
ous flow of urine; the sixth made him sick, and he was more or
less sick at times for three days; but felt no more of his com-
plaints.
I don’t believe it is at all necessary to bring on sickness in
these cases, but an unexpected absence from town prevented me
from seeing him time enough to stop the exhibition of the
medicine.
Case CXUV
October 31st. Mrs. C , of W , Aet. 67. Asthma, and
very thick hard legs of long continuance. The last month or
two her breath worse than usual, her belly swollen, her thighs
anasarcous, and her urine in small quantity. After trying garlic,
376 Medical Classics
squill, and purgatives without advantage, I directed the Digital.
Infos. After taking about five ounces, her urine from thick and
turbid, changed to clear and amber coloured, its quantity consider-
ably increased, and her breathing easy. Contrary to my orders,
but impelled by the relief she had found, she finished the remain-
ing three ounces of the infusion, which made her very sick, and
the free fiow of urine immediately ceased. No medicine was
administered for a fortnight, during which time her complaints
increased. I then directed an infusion of tobacco, which affected
her head, but did not increase her urine. She had recourse again
to the Digitalis infusion, which once more removed the fulness
of the belly, reduced the swellings of her thighs, and relieved her
breath, but had no effect upon her legs.
(p. 95) Case CXLV
Nov. id. Miss B of C , Aet. 11. A very evident
fluctuation in the abdomen, which was considerably distended,
whilst the rest of her frame was greatly emaciated. The pres-
ence of cough, hectic fever, and other circumstances, made it
probable that this apparent ascites was caused by a purulent,
and not a watery effusion. However it was possible I might be
mistaken; the Digitalis was therefore given, but without any
advantage.
The further progress of the disease confirmed my first opinion,
and she died consumptive.
Case CXLVI
Nov. 4th. Mr. P of M , Aet. 40. Subject to trouble-
some nephritic complaints, and after the last attack did not
recover, or void the gravelly concretions as usual, a sense of
weight across his loins continuing very troublesome. The usual
medicines failing to relieve him, I ordered four grains of pulv.
igital. to be taken every other night for a week, and fifteen
grains of mild fixed vegetable alkaly to be swallowed twice a day
in ar ey water. He soon lost all his complaints; but we must
not m t is case too hastily attribute the cure to the Digitalis,
as t e a '«ly has also been found a very useful medicine in sim-
ilar disorders.
The Foxglove 377
(p. 96) Case CXLVII
Nov. 4th. Mr. B of N , Aet. 60. Had been much
subject to gout, but his constitution being at length unable to
form regular fits, he became dropsical. Pulv. sol. Digital, in
doses of two or three grains, at bed-time, gave him some relief,
but did not perfectly empty him. About three months after-
wards he had occasion to take it again ; but it then produced no
effect, and he was so debilitated that it was not urged further.
Case CXLVIII
Nov. 8th. Mr. G , Aet. 35. In the last stage of a phthisis
pulmonalis, was attacked with a most urgent and painful diffi-
culty of breathing. Suspecting this distress might arise from
watery effusion in the chest, I gave him Digitalis, which relieved
him considerably; and during the remainder of his life his breath
never became so bad again.
Case CXLIX
Nov. 13th. Mrs. A of W h , Aet. 68. One of
those rare cases in which no urine is secreted. It proved as
refractory as usual to remedies, and not having ever succeeded
in the cure of this disease, I determined to try the Digitalis.
It was given in infusion, and, after a few doses, the secretion of a
small quantity of urine seemed to justify the attempt. The
next day, however, the secretion (p. 97) ceased, nor could it be
excited again, tho’ at last the medicine was pushed so as to oc-
casion sickness, which continued at intervals for three days.
Case CL
Nov. 20th. Mrs. B — , Aet. 28. In the last stage of a pul-
monary consumption became dropsical. I directed three grains
of the pulv. Digital, to be taken daily, one in the morning, and
two at night. She took twenty grains without any sensible effect.
Case CLI
Nov. 23d. Master W , Aet. 7. Supposed hydrocephalus
internus. A grain of pulv. sol. Digitalis was directed night and
morning. After three days, no sensible effects taking place, it
2j8 Medical Classics
was omitted, and the mercurial plan of treatment adopted. The
child lived near five months afterwards. Upon dissection near
four ounces of water were found in the ventricles of the brain.
Case CLII
Nov. a6th. Mrs. W •, Aet. 65. I had attended this lady
last winter in a very severe peripneumony, from which she nar-
rowly escaped with her life. When the cold season advanced
this winter, she perceived a difficulty in breathing, which grad-
ually became more and more troublesome. I found (p. 98)
her much harrassed by a cough, which occasioned her to expec-
torate a little: the least motion increased her dyspnoea; she could
not lie down in bed; her legs were considerably swelled, her
urine small in quantity. I directed two grains of pulv. Digitalis
made into a pill with gum ammoniac, to he taken every night,
and to promote expectoration, a squill mixture twice in the day.
Her urine in five days became clear and copious, and in a fort-
night more she lost all her complaints, except a cough, for which
she took the lac ammoniacum.
It is not improbable that the squill might have some share in
this cure.
Case CLIII
December 7th. Mr. H , Aet. 4 1. A large fat man, very
subject to gravelly complaints. After an attack in the usual
manner, continued to feel numbness in his lower limbs, and a
sense of weight across his loins. I directed infusum Digitalis to
be given every six hours. Six ounces made him sick, and he took
no more. ^ The next day his urine increased, a good deal of sand
passed with it, and he lost his disagreeable feels, but the sick-
ness did not entirely cease before the fourth day from its com-
mencement.
(p. 99) Case CUV
December 27th. Mr. B , of H , Aet. 55.
1, , * > *■’* 5 5 v Symptoms of
f ,° r f’ at ^. rst obscurely, afterwards more distinctly
marked. Many things were tried, but the squill alone gave re-
The Foxglove 379
lief. At length this failed. About the third month of the dis-
ease, a grain of pulv. Digital, was ordered to be taken night and
morning. This produced the happiest effects. In March fol-
lowing he had some slight symptoms of relapse, which were soon
removed by the same medicine, and he now enjoys good health.
For a more particular narrative see case the first, communicated
by Mr. Yonge.
Case CLV
December 31st. Mrs. B , of E , Aet. 50. An ovarium
dropsy of long continuance. She took three grains of pulv.
Digital, every night at bed time, for a fortnight, but without any
effect.
Case CLVI
A poor man in this town, after his kidneys had ceased to secrete
urine for several days, was seized with hickup, fits of vomiting,
and transient delirium. After examination I was satisfied the
disease was the same as that mentioned at CXLIX. A very
experienced apothecary having tried various methods to relieve
him, I despaired of any success, but determined to try the Digi-
talis. It was accordingly given (p. 100) in infusion. At first it
checked the vomitings, but did not occasion any secretion of
urine.
I7 8 5
The cases which have occurred to me in the course of this year,
are numerous; but as the events of some of them are not yet suffi-
ciently ascertained, I think it better to withhold them at present.
(p. IOl) HOSPITAL CASES, UNDER THE DIRECTION OF THE
AUTHOR
The four following cases were drawn out at my request by
Mr. Cha. Hinchley, late apothecary to the Birmingham Hos-
pital. They are all the Hospital cases for which the Digitalis
was prescribed by me, whilst he continued in that office.
3 So
Medical Classics
Case CLVII
March 15th, 1780. John Butler, Aet. 30. Asthma and
swelled legs. He was directed to take myrrh and steel every
day, and three spoonfuls of infusum Digitalis every night. On
the 8th of April he was discharged, cured of the swellings and
something relieved of his asthmatic affections.
Case CLVI 1 I
November 18th, 1780. Henry Warren, Aet. 60. This man
had a general anasarca and ascites, and was moreover so asth-
matic, that, neither being able to sit in a chair nor lie in bed, he
was obliged constantly to walk about, or to lean forward against
a window or table. You prescribed for him thus.
(p. 102) R. Aq. cinn. spt. oz. iv.
Oxymel. scillit.
Syr. scilit. aa. oz. i. m. cap. cochlear, larg. sexta
quaque hora.
This medicine producing no increased discharge of urine, on
the 25th you ordered the infusion of Digitalis, two spoonfuls
every four hours. After taking this for thirty six hours, his
urine was discharged in very great quantity; his breath became
easy, and the swellings disappeared in a few days, though he took
no more of the medicine. On the 2d of December he was ordered
myrrh and lac ammoniacum, which he continued until the 23d,
when he was discharged cured, and is now in good health.
Case CLIX
November 3d, 1781. Mary Crockett, Aet. 40. Ascites and
universal anasarca. . For one week she took sal. diureticus and
tincture of cantharides, but without advantage. On the 10th
you directed the infusion of Digitalis, a dram and half to half a
pmt, an ounce to be taken every fourth hour. Before this
quantity ^was quite finished, the urine began to be discharged
ery copiously. The medicine was then stopped as you had
irecte n the 15th, being costive, she took a jallap purge,
and on the 24th she was discharged cured.
38 1
The Foxglove
Case CLX
March 16 th, 1782. Mary Bird, Aet. 61. Great fullness about
the stomach; diseased liver, and anasarcous (p. 103) legs and
thighs. For the first week squill was tried in more forms than
one, but without advantage. On the 22d she began with the
Digitalis, which presently removed all the swelling.
She was then put upon the use of aperient medicines and ton-
ics, and on the first of August was discharged perfectly cured.
The three following Cases were drawn up and communicated to
me by Mr. Bayley, who succeeded Mr. Hinchley as apothe-
cary to the Hospital at Birmingham:
Shiffhal, April 26th, 1785.
Dear Sir,
During my residence in the Birmingham General Hospital,
I had frequent opportunities of seeing the great effects of the
Digitalis in dropsy. As the exhibition of it was in the following
instances immediately under your own direction, I have drawn
them up for your inspection, previous to your publishing upon
that excellent diuretic. Of its efficacy in dropsy I have con-
siderable evidence in my possession, but consider myself not at
liberty to send you any other cases except those you had your
self the conduct of. The Digitalis is a very valuable acquisition
to medicine; and, I trust, it will cease to be dreaded when it is
well understood.
I am. Sir, your obedient,
And very Humble servant,
W. Bayley
(p. 104) Case CLXI
Mary Hollis, aged 62, was admitted an out patient of the
Birmingham General Hospital February 12th, 1784, labouring
under all the effects of hydrothorax; her dread of suffocation
during sleep was so great, that she always reposed in an elbow
chair. She was directed to take two grains of Digitalis in powder
every night and morning, and for a few days found great relief;
382 Medical Classics
but, on the eighth day, as she had complained of sickness, and
had' been considerably purged, she was ordered to desist taking
any more of her powders. On the 14th day she was ordered an
ounce of the following infusion twice in a day: R. Sol. Digital,
purp. sicc. drams iss. aq. bullient. lb. ss. digere per semi-horam,
colaturae adde tict. aromatic oz. i. This infusion did not purge,
but sometimes excited nausea, though not sufficient to prevent
her from continuing its use. She grew gradually better, and on
the 6th of May was discharged perfectly cured. The diuretic
effects of the Digitalis were in this instance immediate.
Case CLXII
Edward James, Aet. 21. Admitted March 20th, 1784. Com-
plained of great difficulty of breathing, pain in his head, and
tightness about the stomach, with a trifling swelling of his legs.
Ordered pil. scillit. scruple i. ter de die. On the third day his
legs much more swelled, his breathing more difficult, and in every
respect worse; his pulse very small (p. 105) and quick, complained
when he turned in bed, of something like watter rolling from one
side of the thorax to the other. A remarkable blueness about the
mouth and eyes, and purged considerably from the pil. scill.
Ordered to omit the pills and to take oz.i. of infus. Digitalis every
eight hours; the proportion drams iss. to eight ounces of water
and oz.i. of aq. n. m. sp. — 7th Day, The infusion had neither
purged, nor vomited him: he only complained once or twice of
giddiness. His belly was now very hard, rather black on the
right side of the navel, and his legs amazingly swelled. Ordered
a bolus with rhubarb and calomel, to be taken in the morning,
and oz.ii. julep salin. cum tinct. canthar. gutt. forty ter die. —
12th Day, nearly in the same state, except his breathing was
somewhat more difficult, being now obliged to have his head
considerably raised. Persistat — From this day to the 32d day
he became hourly worse. His belly which at first was only hard,
now evidently contained a large quantity of water, his legs were
more sw el led, and a large sphacelated sore appeared upon each
° U J er ^ nc e ‘ . Inspiration was so much obstructed, that he was
obliged to sit quite upright to prevent suffocation. He made
The Foxglove 383
very little water, not more than eight ounces in a day and a
night, and was much emaciated. Ordered his purging bolus
again, and oz.ii. of a mixture with sal diuretic, oz.ss. to oz.xii.
three times in a day, and a poultice with ale grounds to his legs.
54th day. To this period there was not the least probability
of his existing; his legs and thighs were (p. 106) one continued
blubber, his thorax quite flat, and his belly so large that it meas-
ured within one inch as much as a woman’s in this Hospital the
day she was tapped, and from whom twenty seven pounds of
coagulable lymph were taken. He made about three ounces of
water in twenty-four hours: his penis and scrotum were astonish-
ingly swelled, and no discharge from the sores upon his legs.
Ordered to take a pill with two grains of powdered Fox-glove
night and morning. For a few days no sensible effect, but about
the 60th day he complained of being continually giddy, and had
some little pain in his stomach. He now made much more
water, and dared to sleep. His appetite which through the whole
of his illness had been very bad, was also better. 66th day.
Breathing very much relieved, the quantity of water he made
was three chamber pots full in a day and a night, each pot con-
taining two quarts and four ounces, moderately full. Ordered
to continue his pills, and his legs which were very flabby, to be
rolled.
69th day. His belly nearly reduced to its natural size, still
made a prodigious quantity of water, his appetite very good,
habit of body rather lax, and his complexion ruddy. On the
2d of June, being still rather weak, he was ordered decoct, cort.
oz.ii. ter de die; and on the 12th was discharged from this Hos-
pital perfectly cured.
W. Bayley.
(p. 107) Mr. Bayley ’s respectful compliments to Doctor Wither-
ing: he sends the case of Edward James, which he believes is
pretty correct. He laments not having it in his power to
send the measure of his belly, having unfortunately mislaid
the tape: he heard from James yesterday, and he is perfectly
well.
General Hospital, August 5, 1784.
3 8 4
Medical Classics
Case CLXIII
On the 26th February, 1785, Sarah Ford, aged 42, was ad-
mitted an out-patient of the Birmingham General Hospital: she
complained of considerable pain in her chest, and great difficult
of breathing, her face was much swelled and her thighs and legs
were anasarcous. She had extreme difficulty in making water,
and with many painful efforts she did not void more than six
ounces in twenty-four hours. She had been in this situation
about six weeks, during which time she had taken ammoniacum,
olibanum, and large quantities of squills, without any other effect
than frequent sickness. Upon her commencing an Hospital
patient, the following medicine was exhibited. R. gum ammon-
iac drams ii. pulv. sol. Digital, purp. scruples ii. sp. lavand. comp,
ut fiat pil. 40. cap. ii. nocte maneque. She continued the use of
these pills for a few days, without any sensible effect. On the
eighth day her breathing was much relieved, her legs and thighs
were not so much swelled, and in a day and (p. 108) a night she
made five pints of water. By the 12th day her legs and thighs
were nearly reduced to their natural size. She continued to
make water in large quantities, and had lost her pain in the
thorax. To the 20th of March , she made rapid advances to-
wards health, when not a symptom of disease remaining, she was
discharged.
(p. 109) COMMUNICATIONS FROM CORRESPONDENTS
London, Norfolk-street,
Sir May 31st, 1785.
^ Had the favour of your letter last week; and I shall be very
appy if I can give you any intelligence relating to the Foxglove,
that can answer the purpose in which you are so laudably en-
gaged.
true that my brother, the late Dr. Cawley, was greatly
re eve , and his life, perhaps, prolonged for a year, by a decoc-
tion o t e oxglove root; but why it had not a more lasting effect,
s necessan should tell you that he had all the signs of a dis-
empered viscera, long before any water swellings appeared; it was
The Foxglove 385
manifest that his dropsy was merely symptomatic, and he could
therefore only from time to time have any relief from medicine.
In the year 1776, he returned from London to Oxon. having con-
sulted several physicians at the former place, and Dr. Vivian
at the latter, but without any success; and he was then told of a
carpenter at Oxon. that had been cured of a Hydrops pectoris by
the Foxglove root, and as he (p. 1 10) was a younger, and in other
respects an healthy man, his cure, I believe, remains a perfect one.
I. did not attend my brother whilst he took the medicine, and
therefore I cannot speak precisely to the operation of it; but I
remember, by his letters, that he was dreadfully sick and ill for
several days before the secretion of urine came on, but which
it did do to a greater degree; relieved his breath, and greatly
lessened the swelling in his legs and thighs; but the two in-
stances I have lately seen in this part of the world, are much
stronger proofs of the efficacy of it than my brother’s case.
I am, &c.
Robert Cawley.
N.B. Whenever I have another opportunity of giving the Fox-
glove, it shall be in small doses: — In which I should hope it might
succeed, although it might be more slowly. If you should try
it with success, I should be glad to know what mode you made
use of.
Dr. Cawley’s prescription
R. Rad. Digital, purpur. siccat. et contus. oz.ii.
Coque ex aq. fond, lb.ii. ad. lb.i. colat. liquor, adde aq.
junip. comp, oz.ii.
Mell. anglic oz.i. m. fumat cochl. iv. omni nocte h. f. et
mane.
(p. in) — I have elsewhere remarked, that when the Digitalis
has been properly given, and the diuretic effects produced, that
an accidental over-dose bringing on sickness, has stopped the
secretion of urine. In the present instance it likewise appears,
that violent sickness may be excited, and continue for several
days without being accompanied by a flow of urine; and it is
probable that the latter circumstance did not take place, until
386 Medical Classics
the severity of the former abated. If Dr. Cawley had not had a
constitution very retentive of life, I think he must have died from
the enormous doses he took; and he probably would have died
previous to the augmentation of the urinary discharge. For if
the root from which his medicine was prepared, was gathered in
its active state, he did not take at each dose less than twelve
times the quantity a strong man ought to have taken. Shall we
wonder then that patients refuse to repeat such a medicine, and
that practitioners tremble to prescribe it? Were any of the ac-
tive and powerful medicines in daily use to be given in doses
twelve times greater than they are, and these doses to be repeated
without attention to the effects, would not the patients die, and
the medicines be condemned as dangerous and deleterious? — Yet
such has been the fate of Foxglove!
A Letter to the Author, from Mr. Boden, Surgeon, At
Broseley, in Shropshire
Broseley, 25th May, 1785.
Dear Sir,
Have inclosed the prescriptions that contained the sol. Digital,
which I gave to Thomas Cooke and Thomas Roberts.
Thomas Cooke, Aet. 49, had been ill about two or three weeks.
When I saw him he had no appetite, and a constant thirst: a full-
ness and load in the stomach: the thighs, legs and hands, much
swell d, and the face and throat in a morning; was costive, and
made but little water, which was high coloured; the pulse very
weak, and his breath exceeding bad. June 17th. R. Argent,
viv dr.i. cons, cynosbat. scruples ii. fol. Digital, pulv. gr. xv. f.
pil. xxiv. capt. ii. omni nocte hora decubitus. He was likewise
purged by a bolus of agent, viv. jallap, Digit, elaterium and
calomel which was repeated on the fourth day, to the third
time. Tom Ju?!e 17th to the 29th, the symptoms were mostly
remove , making water freely, and having plenty of stools; in a
ee ’ a ter ewas perfectly well, and remains so ever since. The
cure was finished by steel and bitters.
The Foxglove 387
Thomas Roberts, Aet. 40, had a deformed chest, was obliged
to be almost in an erect posture when in bed; the other symptoms
were nearly the same as Cooke’s. August 3d. The pills pre-
scribed June (p. 1 13) 17th for Cooke. — 17th. A purging bolus
of jalap and Digitalis, once a week. He continued the medicines
till the latter end of August , when he got very well, but the com-
plaint returned in Jan. worse than before. He is now much
better, but I have great reason to believe the liver to be diseased.
I am, with greatest respect,
Your very obliged humble servant,
Daniel Boden.
P. S. The second patient, on his relapse, took Digitalis again,
combined with other things.
Case communicated by Mr. Causer, Surgeon, at Stour-
bridge, Worcestershire
Mr. P of H M , in the parish of Kingswinford,
aged about 60; had been a strong healthy, robust, corpulent man;
worked hard early in life at edge-tool making, and drank freely
of strong malt liquor; for many years had been subject to gout
in the extremities; for a few years past had been very asthmatic,
and the gout in the extremities gradually decreased. When I
first saw him which was Sept. 12, 1779, his legs were anasarcous,
his belly much swelled, and an evident fluctuation of water. His
breathing very bad, an irregular pulse, and unable to lie down.
His easiest (p. 114) posture was standing with his body leaning
over a chair, in which situation he would continue many hours
together, labouring for breath, with the sweat trickling down his
face very profusely; the urine in very small quantity. Diuretics
of every kind I could think of were used with very little or no
advantage. Blisters applied to the legs relieved very consider-
ably for a time, but by no means could I increase the urinary
discharge. Warm stomachic medicines were given, and at the
same time sinapisms applied to the feet, in hopes of enticing
gout to the extremities, but without any good effect . — November
22d. The swelling considerably increasing, an emetic of acet.
scillitic. w T as given, which acted very violently, and increased the
388 Medical Classics
urinary discharge considerably. He continued better and worse,
using different kinds of diuretic and expectorating medicines
until September 1781, when the disease was so much worse, I did
not expect he could live many days. The acet. scillitic. was re-
peated, a table spoonful every half hour, till it acted briskly up-
wards and downwards; but without increasing the urinary dis-
charge. — On the 17th of September I infused dr. iii. of the sol.
Digitalis in oz. vi. of boiling water, for four hours; then strained
it, and added oz. i. of tinct. aromatica. — On the 18th he began
by taking one spoonful, which he was to repeat every half hour,
till it made him very sick, unless giddiness, loss of sight, or any
other disagreeable effect took place. I had never given the medi-
cine before, and had prepared him to expect the operation to be
very severe. I saw him again on the list; he (p. 1 15) had taken
the medicine regularly, till the whole quantity was consumed,
without perceiving the least effect of any kind from it, and con-
tinued well till the evening of the following day, when a little
sickness took place, which increased, but never so as to occasion
either vomiting or purging, but a surprising discharge of urine.
The saliva increased so as to run out of his mouth, and a watery
discharge from his eyes; these discharges continued, with a
continual sickness, till the swelling was totally gone, which hap-
pened in three or four days. He afterwards took steel and bit-
ters; and continued very comfortably, without any return of his
dropsy, until the 7th of April 1782, when he was seized with an
epidemic cough, which was very frequent with us at that time.
His swellings now returned very rapidly, with the greatest diffi-
culty in breathing, and he died in a few days. Blisters and ex-
pectorating medicines were used on this last return.
Mrs. S-
Extract of a letter from Mr. Causer
°T 5 su bj ec t of the following case, was as ill as it is
possi e or woman to be and recover; from the inefficacy of the
me lcmes use , I am convinced no medicine would have saved
. Ut ^ ? J gitalis. I never saw so bad a case recovered; and
tr; hat “ n he m0St reduced state of body, the medicine
m small doses, mil p rove safc and efficacious
The Foxglove 389
(p. 11 6) N.B. The Digitalis, in pills, never occasioned the least
sickness. She took tvvo boxes of them.
Case
January 2d, 1785. Mrs. S , of W , near Kiddermin-
ster, aged 38, has been affected with dropsical swellings of her
legs and thighs, about six weeks, which have gradually grown
worse; has now great difficulty in breathing, which is much in-
creased on moving; a very irregular, intermittent pulse, urine in
very small quantity, and in the seventh month of her pregnancy:
a woman of very delicate constitution, with tender lungs from her
infancy, and very subject to long continued coughs.
R. Pulv. scillae gr. iii.
Jalap gr. x. syr. rosar. solut. tinct. fenn. aa dr. ii. aq. menth.
v. simpl. oz. iss. m. mane fumend.
R/ Pulv. scillae scruple i. G. ammoniac, sapon. venet. aa
drams iss. syr. q. f. f. pilul. 42 cap. iii. nocte maneque.
On the 7th found her worse, and the swelling increased; the
urine about oz. x. in the twenty-four hours.
R. Sol. siccat. Digital, dr. iii. coque in. aq. fontan. oz.xii. ad
oz.vi. cola et adde. aq. juniper, comp, oz.ii. sacchar. alb.
oz.ss. m. cap. cochlear, i. larg. 4tis horis.
(p. 1 17) She took about three parts of the medicine before any
effect took place. The first was sickness, succeeded by a con-
siderable discharge of urine. She continued the medicine till
the whole was consumed, which caused a good deal of sickness
for three or four days.
I saw her again on the 12th. The quantity of urine was much
increased, and the swelling diminished. Pulse and breathing
better.
R. Sol. sicc. Digital. G. assafetid. aa dr. i. calomel, pp. gr. x.
sp. lavand. comp. q. s. siat pilul. xxxii. cap. ii. omni nocte
hora somni.
A plentiful discharge of urine attended the use of these pills,
and she got perfectly free from her dropsical complaints.
March 15th she was delivered: had a good labour, was treated
as is usual, except in not having her breasts drawn, not intending
390 Medical Classics
she should suckle her child, being in so reduced a state. Con-
tinued going on well till the 1 8th, when she was seized with very
violent pains across her lions, at times so violent as to make her
cry out as much as labour pains. Enema cathartic, fot.papav. ap-
plied to the part.
R. Pulv. ipecacoan. gr. vi. opii. gr. iv. syr. q. s. fiat, pilul. vi.
capt. i. 2da quaque hora durante dolore.
(p. 1 1 8) R. Julep, e camphor, sp. minder, aa oz.ii. capt. coch-
lear. i. larg. post singul. pilul.
19th. Breathing short, unable to lie down, very irregular low
pulse scarcely to be felt, fainty, and a universal cold sweat: no
appetite nor thirst, spasmodic pains at times across the loins very
violent, but not so frequent as on the preceding day.
R. Gum ammoniac, assafetid. aa dr. i. camphor, gr. xii. fiat
pilul. 24. capt. ii. 3tia quaque hora in chochlear. ii. mixtur.
seq.
R. Balsam, peruv. dr. iii. mucilag. G. arab. q. s. flor. zinci g.
vi. aq. menth. simp, lb.ss. m.
Applic. Emp. vesicat. femorib. intends.
R. Sp. vol. foetid, elixir, paregor. balsam. Traumatic, aa dr.iii.
capt. cochlear, parv. Urgente languore.
20th. Much the same; makes very little water, and the legs
begin to swell. — Applic. Emp. e pice burgund. lumbis.
23d. The swelling very much increased. — Capt. gutt. xv. acet.
scillitic. ter die in two spoonfuls of the following mixture.
R. Infus. baccar. juniper, oz.vi. tinct. amar. tinct. stomachic,
aa oz.i. m.
(p. 1 1 9) 25th. Much the same.
28th. The swelling considerably increased, in other respects
very much the same.
30th. Breathing very bad, with cough and pain across the
sternum, unable to lie down, legs, thighs, and body very much
swe e , urine not more than four or five ounces in the twenty-
iour hours; hot and feverish, with thirst.
Applic. Emp. vesicat. stomacho et sterno.
R. G. assafetid. scruples ii. pulv. jacob. scruples i. rad. scill.
The Foxglove 391
recent, gr. xii. extract, thebaic, gr. iv. f. pilul. xvi. cap. iv.
omni nocte.
R. Sal. nitr. sal. diuretic, aa dr. ii. pulv. e contrayerv. comp. dr.
i. sacchar. oz. i. emuls. commun. lb. i. aq. cinnam. simpl.
oz. i. m. capt. cochlear, iv. ter die.
April 2d. Much the same, no increase of urine.
3d. Breathing much relieved by the blister, which runs
profusely. Repeated the medicines, and continued them till the
1 2th. The cough very bad, pulse irregular, swelling much in-
creased, urine in very small quantity, not at all increased; great
lowness and fainting. She desired to have some of the pills
which relieved (p. 120) her so much when with child. I was
almost afraid to give them, but the inefficacy of the other medi-
cines gave me no hopes of a cure from continuing them, which
made me venture to comply with her request.
R. Fol. siccat. Digital. G. assafetid. aa dr. i. sp. lavand. comp,
q. s. s. pilul. xxxii. cap. ii. omni mane; et omni nocte cap.
pilul. e styrace gr. vi.
17th. Considerable increase of urine.
2 1st. Swelling a good deal diminished; urine near four pints
in twenty-four hours, which is more than double the quantity
she drinks.
Applic. Emp. vesicat. femoribus internis.
The Digitalis pills and opiate at bed-time continued. Takes a
tea cup of cold chamomile tea every morning.
25th. Swelling much diminished, makes plenty of water,
appetite much mended, cough and breathing better. She omit-
ted the medicine for three days; the urine began to diminish,
the swelling and shortness of breathing worse. On repeating it
for two days, the discharge was again augmented, and a diminu-
tion of the swelling succeeded. She has continued the pills
ever since till the 14th of (p. 121) May ; the dropsical symptoms
and cough are entirely gone, the water is in sufficient quantity,
her strength is recovered, and she has a good appetite. All she
now complains of is a weight across her stomach, which is worse
at times, and she thinks, unless it can be removed, she shall have
a return of her dropsy.
292 Medical Classics
Extract of a Letter from Doctor Fowler, Physician,
at Stafford
I Understand you are going to publish on the Digitalis, which
I am glad to hear, for I have long wished to see your ideas in
print about it, and I know of no one (from the great attention
you have paid to the subject) qualified to treat on it but yourself.
There are gentlemen of the faculty who give verbal directions to
poor patients, for the preparing and taking of an infusion or
decoction of the green plant. Would one suppose that such
gentlemen had ever attended to the nature and operation of a
sedative power on the functions, particularly the vital? Is not
such a vague and unscientific mode of proceeding putting a two
edged sword into the hands of the ignorant, and the most likely
method to damn the reputation of any very active and powerful
medicine? And is it not more than probable that the neglect
of adhereing to a certain and regular preparation of the nicotiana,
and the want (of what you emphatically call) a practicable dose,
have been the chief causes of the once rising reputation of (p. 122)
that noted plant being damned above a century ago ? In short,
the Digitalis is beginning to be used in dropsies, (although some
patients are said to go off suddenly under its administration)
somewhat in the style of broom ashes; and, in my humble
opinion, the public, at this very instant, stand in great need of
your precepts, guards, and cautions towards the safe and successful
use of such a powerful sedative diuretic; and I have no doubt of
your minute attention to those particulars, from a regard to the
good and welfare of mankind, as w r ell as to your own reputation
with respect to that medicine.
I remember an officer in the Staffordshire militia, who died
here of a dropsy five years ago. The Digitalis relieved him a
number of times in a wonderful manner, so that in all probability
e might have obtained a radical cure, if he w r ould have refrained
irom hard drinking. I understood it was first ordered for him
^ , a lc . a ^ g en deman, and its sedative effects proved so mild,
an iuretac operation so powerful, that he used to prepare it
a terwar s or himself, and w r ould take it with as little ceremony
e wo is tea. It is said, that he was so certain of its sue-
The Foxglove 393
cessful operation, that he would boast to his bacchanalian com-
panions, when much swelled, you shall see me in two days time
quite another man.
Cases communicated by Mr. J. Freer, jun. Surgeon, in
Birmingham.
Case I
Nov. 1780. Mary Terry, aged 60. Had been subject to
asthma for several years; after a severe fit of it her legs began to
swell, and the quantity of urine to diminish. In six weeks she
was much troubled with the swellings in her thighs and abdomen,
which decreased very little when she lay down: she made not
quite a pint of water in the twenty-four hours. I ordered her
to take two spoonfuls of the infusion of Foxglove every three
hours. By the time she had taken eight doses her urine had in-
creased to the quantity of two quarts in the day and night, but
as she complained of nausea, and had once vomited, I ordered
the use of the medicine to be suspended for two days. The
nausea being then removed, she again had recourse to it, but at
intervals of six hours. The urine continued to discharge freely,
and in three weeks she was perfectly cured of her swellings.
Case II
December , 1782. A poor woman, who had been afflicted with
an ague during the whole of her pregnancy, and for two months
with dropsical swellings of the feet, legs, thighs, abdomen, and
labia pudenda; was at the expiration of the seventh month
(p. 124) taken in labour. On the day after her delivery the ague
returned, with so much violence as to endanger her life. As
soon as the fit left her, I began to give her the red bark in sub-
stance, which had the desired effect of preventing another par-
oxysm. She continued to recover her health for a fortnight, but
did not find any diminution in the swellings; her legs were now so
large as to oblige her to keep constantly on the bed, and she made
very little water. I ordered her the infusion of Foxglove three
times a day, which, on the third day, produced a very copious
discharge of urine, without any sickness; she continued the use
Medical Classics
of it for ten days, and was then able to walk. Having lost all
her swe llin gs, and no complaint remaining but weakness, the
bark and steel compleated the cure.
Extract of a Letter from Doctor Jones, Physician, in Lich-
field
Axxious to procure authentic accounts from the patients, to
whom I gave the Foxglove, I have unavoidably been delayed
in answering your last favour. However, I hope the delay will
be made up by the efficacy of the plant being confirmed by the
enquiry. Long cases are tedious, and seldom read, and as seldom
is it necessary to describe every symptom; for every case would be
a history of dropsy. I shall therefore content myself with speci-
(p. 125) fying the nature of the disease, and when the dropsy is
attended with any other affection shall notice it.
Two years have scarcely elapsed since I first employed the
Digitalis; and the success I have had has induced me to use it
largely and frequently.
Case I
Ann "Willott, 50 years of age, became a patient of the Dispen-
sary on the nth of April 1783. She then complained of an en-
largement of the abdomen, difficulty of breathing, particularly
when lying, and costiveness. She passed small quantities of
high-coloured urine; and had an evident fluctuation in the belly.
Her legs were oedematous. Chrystals of tartar, squills, &c.
had no effect. The 13th of June she took two spoonfuls of a
decoction of Foxglove, containing three drams of the dry leaves,
in eight ounces, three times a day. Her urine soon increased,
and in a few days she passed it freely, which continued, and her
breath returned.
L,ase 11
Mr.
... ’ ^5 }"ears of age, had been long subject to dropsical
swellings of the legs, and made little water. Two spoonfuls of
the same decoction twice a day, soon relieved him.
395
The Foxglove
Case III
Mrs. ■, aged 70 years. A lady frequently afflicted with the
gout, and an asthmatical cough. After a long continuance of
the latter, she had a great diminution of urine, and considerable
difficulty of breathing, particularly on motion, or when lying.
Her body was much bound. There was, however, no apparent
swelling. She took three spoonfuls of an aperient decoction of
forty-five grains in six ounces and a half, every other morning.
The urine was plentiful those days, and her breathing much re-
lieved. In two or three weeks after the use of it she was per-
fectly restored. The purgative medicine neither increased the
urine, nor relieved the breathing, till the Foxglove was added.
This spring she long laboured with the gout in her stomach,
which terminated in a fit in her hand. During the whole of this
tedious illness, of nearly three months, she passed little urine,
and her breathing was again short.
She took the same preparation of Foxglove without any
diuretic effect, and afterwards two and three grains of the powder
twice a day with as little. The dulcified spirits of vitriol, how-
ever, quickly promoted the urinary secretion.
(p. 127) Case IF
Mr. C , 46 years of age, had dropsical swellings of the legs,
and passed little urine. He took the decoction with three drams,
and was soon relieved.
Case V
Lady , took three grains of the dried leaves twice a day,
for swelled legs, and scantiness of urine, without effect.
Case VI
Mrs. Slater, aged 36 years. For dropsy of the belly and legs,
md scantiness of urine, of several weeks standing, took three
grains of the powder twice a day, and was quite restored in ten
days. She took many medicines without effect.
3^6 Medical Classics
Case VII
’vij-s. p , in her 70th year, took three grains of the powder
twice a day, for scantiness of urine, and swelled legs, without
effect.
Case VIII
Ann Winterleg, in her 26th year, had dropsical swellings of
the legs, and passed little urine: she was relieved by two drams,
in an eight ounce decoction.
(p. 128) Case IX
William Brown, aged 76. In the last stage of dropsy of the
belly and legs, found a considerable increase of his urine by a
decoction of Foxglove, but it was not permanent.
Case X
Mr. , — years of age, and of very gross habit of body,
became highly dropsical, and took various medicines, without
effect. One ounce of the decoction, with three drams of the dry
leaves in eight ounces, twice or three times a day, increased his
urine prodigiously. He was evidently better, but a little at-
tendant nausea overcame his resolution, and in the course of
some weeks afterwards he fell a victim to his obstinacy.
Case XI
Mrs. Smith, about 5° years of age, after a tedious illness of
many weeks, had a jaundice, and became dropsical in the legs.
Two spoonfuls of the decoction, with three drams twice a day,
increased her urine, and abated the swelling.
Case XII
. Widow Chatterton, about 60 years of age. Took the decoc-
tion in the same way for dropsy of the legs, with little effect.
(p. 129) Case XIII
~ Ge . n ff s > about thirty-four years of age, was delivered
of three children, and became dropsical of -the abdomen. She
passed little or no urine, had constant thirst, and no appetite.
The Foxglove 397
She took two spoonfuls of an eight ounce decoction, with three
drams twice a day. By the time she had finished the bottle,
(which must have been on the fourth day,) she had evacuated
all her water, and could go about. Her appetite increased with
every dose, and she recovered without farther help.
Case XIV
Miss M M , in her 20th year. Had been infirm from
her cradle, and, after various sufferings, had an astonishing
oedematous swelling of one leg and thigh, of many weeks stand-
ing. She passed little or no urine, and had all her other com-
plaints. She took 2 spoonfuls of an eight oz. decoction of two
drams, twice a day. Her urine immediately increased; and, on
the third day, the swelling had entirely subsided.
Case XV
Mr. P , 65 years of age, and of a full habit of body. Had
lived freely in his youth, and for many years led rather an inac-
tive life. His health was much impaired several months, and
he had a considerable distention, and evident fluctuation in
(p. 130) the abdomen, and a very great oedema of the legs and
thighs. His breathing was very short, and rather laborious,
appetite bad, and thirst considerable. His belly was bound, and
he passed very small quantities of high-coloured urine, that de-
posited a reddish matter. He had taken medicines some time,
and, I believe, the Digitalis; and had been better.
A blister was applied to the upper and inside of each thigh;
he took two spoonfuls of the decoction, with three drams of the
dry leaves, two or three times a day; and some opening physic
occasionally.
He lived at a considerable distance, and I did not visit him a
second time; but I was well informed, about ten days or a fort-
night afterwards, that his urine increased amazingly upon taking
the decoction, and that the water was entirely evacuated.
Case XVI
Mrs. G , aged 50 years. After being long ailing, had a
large collection of water in the abdomen and lower extremities.
2gS Medical Classics
Her urine was high-coloured, in small quantities, and had a red-
dish sediment. She took the decoction of Digitalis, squills,
8 cc. without any effect. The chrystals of tartar, however, cured
her speedily.
(p. 131) Case XVII
Mr. , about 50 years of age, complained of great tension
and pain across the abdomen, and of loss of appetite; his urine,
he thought, was less than usual, but the difference was so trifling
he could speak with no certainty: his belly seemed to fluctuate.
Among other things he tried the Foxglove leaves dried, twice a
day; and, although it appeared to afford him relief, yet the effect
was not permanent.
Case XVIII
Mr. W , aged between 60 and 70 years; and rather cor-
pulent: was considerably dropsical, both of the belly and legs,
and his urine in small quantities. Three grains of the dry leaves,
twice a day, evacuated the water. in less than a fortnight.
Case XIX
Sarah Taylor, 40 years of age, was admitted into the Dis-
pensary for dropsy of the abdomen and legs; and was relieved
by the Decoctum digitalianum.
Case XX
Lydia Smith, aged 60. Dispensary. Laboured many years
under an asthma, and became dropsical. She took the decoction
without effect.
(p. 132) Case XXI
John Leadbeater, aged 15 years. Had a quotidian intermit-
tent, which was removed by the humane assistance of an amiable
young lady. His intermittent was soon attended by a very con-
siderable ascites; for which he became a patient of the Dispen-
sary. _ He took a decoction of Foxglove night and morning. His
fomYa nC s reaSed mmediately ’ and he Iost a11 h5s complaints in
399
The Foxglove
Case XXII
William Millar, aged 50 years. Admitted into the Dispensary
for a tertian ague, and general dropsy. The dropsy continuing
after the ague was removed, and his urine being still passed in
quantities; he took the powdered leaves, and recovered his health
in five days.
Case XXIII
Ann Wakelin, 10 years of age. Had for several weeks a dropsy
of the belly after an ague. She took a decoction of Foxglove,
which removed all complaint fy the fourth day.
Case XXIV
Ann Meachime; a Dispensary patient. Had an ascites and
scantiness of urine. She took the powder (p. 133) of Foxglove,
and evacuated all her water in three days.
It may not be improper to observe, 1st. That various diuret-
ics had long been given in many of these cases before I was con-
sulted. And, 2dly. That the exhibition of the Foxglove waa
but seldom attended with sickness.
Remarks
These Cases, thus liberally communicated by my friend, Dr,
Jones, are more acceptable, as they seem to contain a faithful
abstract from his notes, both of the unsuccessful as well as the
successful Cases.
The following Tabular View of them will give us some Idea of
the efficacy of the Medicine.
Anasarca 7 Cases
Cured, 3
Relieved, 1
Failed, 3
Ascites 5 Cases /^ ur . ec ^ \
[Relieved, 1
Oedematous leg 1 Case — Cured, 1
Cured, 4
Ascites and anasarca 7 Cases s Relieved, 2
Failed, 1
Medical Classics
400
Asthma and dropsy
Hydrothorax and gout
— — , ascites and anasarca. . .
(p. 134) A Case of anasarca
Surgeon, in
1 Case — Failed, 1
1 Case — Cured, 1
1 Cases — Cured, 2.
communicated by Mr. Jones,
Birmingham
Dear Sir,
Having lately experienced the diuretic powers of the Foxglove,
in a case of anasarca; I do myself the pleasure of communicating
a short history of the treatment to you.
I am, &c.
W. Jones.
Birmingham,
May 17th, 1785.
My patient, Mrs. C , who is in her 51st year, had the fol-
lowing symptoms, viz. alternate swellings of the legs and abdo-
men, a little cough, shortness of breath in a morning, thirst,
weak pulse, and her urine, which was so small in quantity as
seldom to amount to half a pint in twenty-four hours, deposited a
clay-coloured sediment.
April 16th, 1785, I directed the following form:
R. Sol. Digitalis siccat. dr. ii.
Aq. fontanae bullient. oz. viii. s. infus. et cola.
Summat cochl. larga iii. o. n. et mane.
On the 17th she had taken twice of the infusion, and though
by mistake only two teaspoonfuls for a (p. 135) dose, yet the
quantity of urine was increased to about a pint in the twenty-
four hours. She was then directed to take two tablespoonfuls
night and morning. And,
On the 1 8th, a degree of nausea was produced. A pint and
half of urine was made in the last twenty-four hours. During
the time above specified she had two or three stools every day.
The infusion was now omitted.
On the 19th the swellings of the legs was removed. A degree
of nausea took place in the morning, and increased so much dur ing
the day, that she vomitted up all her food and medicine. As
she was very low, and complained of want of appetite, a cordial
The Foxglove 4.01
julep was directed to be taken occasionally, as well as red port
and water, mint tea, &c. She informed me that whatever she
took generally staid about an hour before it came up again, and
that the mint tea staid longest on the stomach. The vomiting
decreased gradually, and ceased on the 22d. The discharge of
urine remained considerable during the three following days, but
its quantity was not measured.
lid. A dose of neutral saline julep was directed to be taken
every fourth hour.
On the 23d she complained of thirst, and thought the dis-
charge of urine not so copious as on the preceding days, therefore
the saline julep was continued (p. 136) every fourth hour, with
the addition of thirty drops of the following medicine:
R. Aceti scillitic. dr. vi.
Tinct. aromat. dr. ii.
Tinct. thebaic, gutt. xx. m.
The bowels have been kept open from the 19th, by the oc-
casional use of emollient injections.
On the 24th the legs were much swelled again ; she complained
of languor and a degree of nausea. The discharge of urine in-
creased a little since the 23d. Her pulse was low and her tongue
white. The urine, which had been rendered clear by the in-
fusion of Foxglove, now deposited a whitish sediment.
On the 25th her appetite began to return, the swelling of the
legs diminished, and she thought herself much relieved. The
urine was considerable in quantity, and clear.
On the 26th she was thirsty and languid. The swelling was
removed; the quantity of urine discharged in the last twenty-
four hours was about a pint. She continued to mend from this
time, and is now in good health.
A giddiness of the head, more or less remarkable at times, was
observed to follow the use of the Foxglove, and it lasted nine or
ten days.
(p. 137) This is the second time that I have relieved this
patient by the infusion of Foxglove. I used the same proportion
of the fresh leaves the first time as I did of the dried ones the
last. The violent vomiting which followed the use of the in-
2 Medical Classics
fusion made with the dried leaves, did not take place with the
fresh, though she took near a pint made with the same proportion
of the herb fresh gathered.
Remarks
The above is a very instructive case, as it teaches us how small
a quantity of the infusion was necessary to effect every desirable
purpose. At first sight it may appear from the concluding para-
graph, that the green leaves ought to be preferred to the dried
ones, as being so much milder in their operation; but let it be
noticed, that the same quantity of infusion was prepared from
the same weight of the green as of the dried leaves, and conse-
quently, as will appear hereafter, the infusion with the dried
leaves was five times the strength of that before prepared from
the green ones. We need not wonder, therefore, that the effects
of the former were so disagreeable, when the dose was five times
greater than it ought to have been. But what makes this matter
still more obvious, is the mistake mentioned at first, of two tea
spoonfuls only being given for a dose. Now a tea spoonful, con-
taining about a fourth or a fifth part of the contents of a table
spoon, the dose then given, was very nearly the same as that
which had before been taken of the (p. 338) infusion of the green
leaves, and it produced precisely the same effects for it increased
the urinary discharge, without exciting the violent vomiting.
Letter from Doctor Johnstone, Physician, in Birmingham
Dear Sir,
The following cases are selected from many others in which I
have given the Digitalis purpurea; and from repeated experience
of its efficacy after other diuretics have failed, I can recommend
it as an effectual, and when properly managed, a safe medicine.
Birmingham, May 26,
j 785 -
I am, &c.
E. Johnstone.
March 8th, 1783, 1 was called to attend Mr. G a gentleman
of robust habit, who had led a regular and temperate life. Aet.
The Foxglove 403
68. He was affected with great difficulty of respiration, and
cough particularly troublesome on attempting to lie down,
oedematous swellings of the legs and thighs, abdomen tense and
sore on being pressed, pain striking from the pit of the stomach
to the back and shoulders; almost constant nausea, especially
after taking food, which he frequently threw up; water thick
and high-coloured, passed with difficulty and in (p. 139) small
quantity; body costive; pulse natural; face much emaciated, eyes
yellow and depressed. He had been subject to cough and diffi-
culty of breathing in the winter for several years; and about four
years before this time, after being exposed to cold, was suddenly
deprived of his speech and the use of the right side, which he
recovered as the warm weather came on; but since that time had
been remarkably costive, and was in every respect much debili-
tated. He first perceived his legs swell about a year ago; by the
use of medicines and exercise, the swellings subsided during the
summer, but returned on the approach of winter, and gradually
increased to the state in which I found them, notwithstanding he
had used different preparations of squills and a great variety of
other diuretic medicines. I ordered the following mixture.
R. Foliorum Digitalis purpur. recent, dr. iii. decoque ex aq.
fontan. oz. xii ad oz. vi colaturae adde Tinctur. aromatic. Syr.
zinzib. aa oz.i. m. capt. cochl. duo larga secunda quaque
hora ad quartam vicem nifi prius nausea supervenerit.
March 9th. He took four doses of the mixture without being
the least sick, and made, during the night upwards of two quarts
of natural coloured water.
(p. 140) 10th. Took the remainder of the mixture yesterday
afternoon and evening, and was sick for a short time, but made
nearly the same quantity of water as before, the swellings are
considerably diminished, his appetite increased, but he is still
costive.
R. Argent, viv. balsam peruv. aa dr.ss. tere ad extinctionem
mere, et adde cum. ammon. scruples iii. aloes socotorin. dr.
ss. rad. scil. recent, scruples ss. syr. simpl. q. s. s. mass, in
pil. xxxii divid. cap. iii. bis in die.
14th. Continued to make water freely. The swellings of
4 04 Medical Classics
his legs have gradually decreased; soreness and tension of the
abdomen considerably less.
Omittant. pil. cap. mistur. c. decoct. Digitalis &c. 3tia quaque
hora ad-3tiam vicem.
15th. Made a pint and a half of water last night, without
being in the least sick, and is in every respect considerably better.
Repet. Pillul. ut antea.
21st. Makes water as usual when in health, and the swellings
are entirely gone.
R. Infus. amar. oz. v. tinctur. Rhei spirit, oz. ii. spirit vitriol,
dulc. dr. ii. syr. zinzib. dr. vi. m. cap. cochl. iii. larg. ter in die.
He soon gained sufficient strength to enable him to go a jour-
ney, and returned home in much better (p. 141) health than he
had been from the time he was affected with the paralytic stroke,
and excepting some return of his asthmatic complaint in the
winter, hath continued so ever since.
Case II
R Howgate, a man much addicted to intemperance, par-
ticularly in the use of spirituous liquors, Aet. 60, was admitted
into the Hospital near Birmingham, May 17, 1783. He com-
plained of difficulty of breathing, attended with cough, par-
ticularly troublesome on lying down; drowsiness and frequent
dozing, from which he was roused by startings, accompanied with
great anxiety and oppression about the breast, oedematous swell-
ings of the legs; constant desire to make water, which he passed
with difficulty, and only by drops; pulse weak and irregular;
body rather costive; face much emaciated; no appetite for food. —
Cap. pil. scil. iii. ter in die.*
May 20th. The pils have had no effect. — Cap. mistur. c.f
Decoct. Digital. &c. cochl. ii. larg. 3tia quaque hora, ad 3tiam
vicem.
May. 21st. Made near two quarts of water in the night, with-
out being in the least sick. He continued (p. 142) the use of the
mixture three times in the day till the 30th, and made about
.* R- Rad ‘ sdL recent - sa P°n. castiliens. pulv. Rhei opt. aa. scruples i. ol. jump. gutt.
xvi. syr. bals. q. s. f. mass, in pil. xxiv. divid.
f Prepared in the same manner as in the former case.
The Foxglove 4.05
three pints of water daily, by which means the swellings were en-
tirely taken away; and his other complaints so much relieved,
that on the 6th of June he was dismissed free from complaint,
except a slight cough. But returning to his old course of life,
he had had frequent attacks of his disorder, which have been
always removed by using the Digitalis.
Extract of a letter from Mr. Lyon, Surgeon, at Tamworth
— Mr. Moggs was about 54 years of age, his disease a dropsy
of the abdomen, attended with anasarcous swellings of the limbs,
&c. brought on by excessive drinking. I believe the first symp-
toms of the disease appeared the beginning of November, 1776;
the medicines he took before you saw him, were squills in differ-
ent forms, sal diureticus and calomel, but without any good
effect; he begun the Digitalis on the 10th of July 1777; a few doses
of it caused a giddiness in the head, and almost deprived him of
sight, with very great nausea, but very little vomiting, after
which a considerable flow of urine ensued, and in a very short
time, a very little water remained either in the cavity of the abdo-
men, or the membrana adiposa, but he remained excessive weak,
with a fluttering pulse at the rate of 150 or frequently 160 in a
minute; he kept pretty free from water for upwards of twelve
months; it then (p. 143) collected, and neither the Digitalis nor
any other medicine would carry it off. I tapped him the ad of
August 1779 th e usual place, and took some gallons of water
from him, but he very soon filled again, and as he had a very
large rupture, a considerable quantity of the water lodged in the
scrotum, and could not be got away by tapping in the usual place.
I therefore (on the a8th of the same month) made an incision
into the lower part of the scrotum, and drained off all the water
that way, but he was so very much reduced, that he died the 8 th
or 9th of September following, which was about two years and
two months after he first begun the Digitalis.
I have had several dropsical patients relieved, and some per-
fectly recovered by the Digitalis, since you attended Mr. Moggs,
but as I did not take any notes or make any memorandums of
them, cannot give you any of them.
4_o 6 Medical Classics
Communications from Dr. Stokes, Physician, in Stourbridge
Dear Sir,
I Accept with pleasure your invitation to communicate what I
know respecting the properties of Digitalis ,* and if an account of
what others had discovered before you,* with a detail (p. 144)
of my own experience, shall be allowed the merit of at least a
-well meant acknowledgment, for the early communication you
were so kind to make me, of the valuable properties you had found
in it; I shall consider my time as well employed. A knowledge
of what has been already done is the best ground work of future
experiment; on which account I have been the more full on this
subject, in hopes that given with the cautions which you mean
to lay down in the cure of dropsies, it may prove alike useful
in that of other diseases, one of which stands foremost among the
opprobria of medicine.
Case I ■
Mrs. M . Orthopnea, pain, and excessive oppression at
the bottom of the sternum. Pulse irregular, with frequent inter-
missions. Appetite very much impaired. Legs anasarcous.
Empl. vesicator. pectori dolent.
Inf us. Digital, e dr. iii. ad. aq. &c. oz. viii. cochl.j. 0. h. donee
nausea excitetur vel diuresis satis copiosa proveniat.
I ordered it of the above strength, and to be repeated often,
on account of the great emergency of the case, but the nausea
excited by the first dose prevented its being given at such short
intervals. A 3d dose I found had been given, which was followed
by vomitings. All her complaints gradually abated, (p. 145)
but in about a fortnight recurred, notwithstanding the use of
infus. amar. &c.
Dec. 2. Intus. Digit, e. dr. iss. ad. aq. & c . oz. viii. cochl. it.
horis &c. u. a.
Complaints gradually abated, swellings of the legs nearly gone
down.
* See this account in the Introduction.
The Foxglove 407
About a month afterwards you was desired to visit this pa-
tient.*
1785
Case
Jan. 5th. Mrs. M , Aet. 48. Hydrothorax and anasar-
cous legs, of eight months duration. She had taken jallap,
squill, salt of tartar, and various other medicines. I found her
in a very reduced state, and therefore directed only a grain and
half of the Pulv. Digital, to be given night and morning. This
in a few days encreased the secretion of urine, removed her diffi-
culty of breathing, and reduced the swelling of her legs, without
any disturbance to her system.
Three months afterwards, a severe attack of gout in her legs
and arms, removing to her head, she died.
Dr. Stokes had an opportunity of examining the dead body,
and I had the satisfaction to learn from him, that there did not
appear to have been any return of the dropsy.
(p. 146) On the examination of the body I noticed, among
others, the following appearances.
About 3/4 oz. of bloody water flowed out, on elevating the
upper half of the scull, and a small quantity also was found at the
base.
Brain. Blood-vessels turgid with blood, and many of those
of considerable size distended with air.
A very slight watery effusion between the Pia Mater and
Tunica arachnoidea. About 3/4 oz. of watery fluid in the
lateral ventricles.
Thorax. In the left cavity about 4 oz. of bloody serum; in
the right but little. Lungs, the hinder parts loaded with blood.
Adhesions of each lobe to the pleura. Pericardium containing
but a very small quantity of fluid. Heart containing no coagula
of blood. Valves of the Aorta of a cartilaginous texture, as if
beginning to ossify.
* For reasons assigned at p. loo, I did not intend to introduce any case, occuring under
my own inspection, in the course of the present year; but it may be satisfactory to con-
tinue the history of this disease, as Dr. Stokes’s narrative would otherwise be incomplete.
40 8 Medical Classics
Abdominal Viscera natural, and a profusion of Fat under the
integuments of the abdomen and thorax, in the former to the
thickness of an inch and upwards, and in very considerable
quantity on the mesentery, omentum, kidneys, &c.
Obs. The intermitting pulse should seem to have been owing
to effusions of water in some of the cavities of the breast, as it
disappeared on the removal of the waters.
(p. 147) Case II
Mrs. C of K , Aet. 80. Orthopnoea, with sense of
oppression about the proecordia. Unable to lie down in bed
for some nights past. Anasarca of the lower extremities. Urine
very scanty. Complaints of six weeks standing. Had taken
sal. diuret . c. ol. jnnip. — Calom. c. jalap , et gambog. — Et ol. junip.
c. ol. terebinth, without effect.
Feb. 7 Inf us. Digital, e. dr. Hi. ad aq. &c. oz. viii. cochl. ii.
jtis horis. Ordered to drink largely of inf us. baccar. junip.
The third dose produced great nausea which continued ten hours,
during which time the urine made was about a quart. The
next day her apothecary directed her to begin again with it.
The second dose produced vomiting. During the next twenty
hours she made two quarts of water, about four times as much as
she drank.
From this time she took no more of the inf us. Digital, but con-
tinued the inf. bacc. junip. until about March 2d , when all the
swellings were gone down, her respiration perfectly free, and she
herself quite restored to her former state of health. On the 29th
she had an attack of jaundice which was some time after removed;
since which she has enjoyed a good state of health, excepting that
for some little time past her ancles have been slightly oedematous,
which will I trust soon yield to strengthening medicines.
(p. 148) Case III
Mrs. M G j Aet. 64. Has had sore legs for these
thirty -four years past. Orthopnoea. Sense of oppression at
the praecordia. Pulse intermitting. Legs anasarcous. Urine
scanty, high-coloured.
The Foxglove 409
Inf us. Digital c. dr. iss ad. aq. bull oz. viii. cochl. it. 41'is horis.
Took six doses, when nausea was excited. Urine a quart
during the course of the night. The flow of urine continued, and
complaints relieved. Sal. Mart. c. extr. gent, and afterwards
with the addition of extr. cort. for which last ingredient she had a
predilection, confirmed the cure.
On the same day the next year I was called in to her for a sim-
ilar train of symptoms, excepting that the pulse was but just
perceptibly irregular.
Infus. Digital u. a. praescrpt.
The directions on the phial not being attended to, two doses of
it were given after a nausea had been excited , which, with occasional
vomitings, became exceedingly oppressive. A saline draught,
given in Dr. Hulme’s method, a draught sal c. c. gr. xi. c. conf.
card. gr. x. produced no immediate effect, but the nausea gradu-
ally abating, inf. bacc. junip. was ordered; but this appeared to
augment it, (p. 149) and a great propensity to sleep coming on,
I directed sal. c. c. conf. card, aa gr. viii. 4 tis horis , which removed
the unpleasant symptoms and myrrh, c. sal. mart, completed the
cure. During the use of the above medicines, the urine was aug-
mented, and the pulmonary complaints removed, even before
the nausea left her; and the sores of her legs which were much
inflamed before she began with the infus. Digital, in a day’s
time assumed a much healthier appearance, and on her other
complaints going off, they shewed a greater tendency to heal
than she had ever observed in them for twenty years before.
This instance is a very pleasing confirmation of the experience
of Hulfe and Dr. Baylies, and of the advantage to be derived
from a medicine, which, while it helps to heal the ulcers, removes
that from the constitution which often renders the healing of
them improper.
In one case in which I ordered it, the infusion, instead of digest-
ing three hours as I had directed, was suffered to stand upon the
leaves all night. The consequence was that the first dose pro-
duced considerable nausea.
The two following cases, with which I have been favoured by
a physician very justly eminent, convince me of the necessity
^xo Medical Classics
there is that every one who discovers a new medicine, or new
virtues in an old one, should, in announcing such discoveries,
publish to the world the exact manner in which he exhibits (p. 1 50)
such medicines, with all the precautions necessary to obtain the
promised success.
In these (says my correspondent) “the infusion was given in
small doses, repeated every hour or two, till a nausea was raised,
when it was omitted for a day or perhaps two, and then repeated
in the same manner.”
“An Ascites emptied by it, but filled again very speedily,
though its use was never discontinued , and who afterwards found
no salutary effects from it. Ended fatally.”
“In an Anasarca it sometimes increased the quantity of urine,
and abated the swelling, but which as often returned in as great a
degree as before, though the medicine was still given , and always
increased in quantity so as to excite nausea. Ended fatally.”
“I have tried it in many other cases, but found very little
difference in the success attending it.”
May we not be allowed to conjecture that the inefficacy of
its continued use is owing to its narcotic property gradually dimin-
ishing the irritability of the muscular fibres of the absorbents,
or possibly of the whole vascular system, and thus adding to
that weakened action which seems to be the cause of the general-
ity of dropsies, which leads us to caution the medical experi-
menter against trying it, at least (p. 151) against its continued use,
even in small doses , in other diseases of diminished energy, as
continued fever, palsy, &c.
I remain with the greatest truth.
Your obliged and affectionate friend,
Jonathan Stokes.
Stourbridge,
May 17, 1785.
The three following Hospital Cases, which Dr. Stokes had an
opportunity of observing, are related as instances of bad
practice, and tend to demonstrate how necessary it is when
one physician adopts the medicine of another, that he should
also at first rigidly adopt his method.
The Foxglove 41 1
Case I
Esther K , Aet. 33. General anasarca, ascites, and dysp-
noea, of seven months duration.
Decoct, e Digit, dr. iv. c. aq. lb. i. coquend. ad. lb. ss. cap. oz. i.
2 dis. 'horis. ist Day. 4th dose made her sick, ad Day. The
first dose she took today produced vomiting.
(p. 15a) 3d Day. Minuatur dosis ad oz. ss. This stayed upon
her stomach, but produced an almost constant sickness. Stools
more frequent, water scarce sensibly increased; and her swellings
not at all reduced.
4th Day. Cap. Calomel, gambog. scill. &c.
Obs. Sufficient time was not allowed to observe its effects,
neither was the patient enjoined the free use of diluents. The
disease terminated fatally.
Case II
William T , Aet. 4a. Ascites, with cough and dyspnoea.
Abdomen very much distended. The rest of his body highly
emaciated. Urine thick, high coloured, and in very small quan-
tity.
Decoct Digit. («. in Esther K .) /ftis horis.
ist Day of taking it. The 4th dose produced sickness.
ad. Vomiting after the second dose.
loth. Urine increased to lb. vi.
nth. Flow of urine continues. Abdomen quite flaccid.
(p. 153) iath. Abdomen not diminished.
15th. A smart purging came on, and the flow of urine di-
minished.
a3rd. Belly much bound. Took a cathart. powder, which
was followed by a diminution of the abdomen.
apth. To take a cathart. powder every 4th morning, contin-
uing the decoct. Digit.
3ad. Urine exceedingly scanty.
35th. Vin. scill. oz. ss. 0. m. &c. This produced diuretic
effects.
44th. Tapped. Terminated fatally.
Obs. Here the medicine was continued till it ceased to produce
412 Medical Classics
diuretic effects; and these effects were not aided by any strengthen-
ing remedies.
Case III
George R , Aet. 52. Ascites, general anasarca, and dysp-
noea. His legs so greatly distended that it was with great diffi-
culty he could draw the one after the other.
(p. 154) Inf us. Digital, dr. Hi ss. ad. aq. lb. ss. cap. oz. i. altem.
Jioris donee nauseam excitaverit. Rep. 3 tiis diebus. tempore
intermedia cap. sol. guaic. oz. i. ter in die ex inf. sinap.
1st Day of taking it. Became sickish tov/ards night.
2d Day. Made a great quantity of v/ater during the night,
and spat up a great deal of watery phlegm. The first dose he
took in the morning has produced a sickness which has continued
all day, but he has never vomited.
3d Day. The change in his appearance so great as to make it
difficult to conceive him to be the same person. Instead of a
large corpulent man, he appeared tall, thin, and rather aged.
Breathes freely, and can walk up and down stairs without incon-
venience.
4th Day. Decoct, bacc. junip. and cyder for common drink.
6 th Day. A second course of his medicine produced a flow of
urine almost as plentiful as the former, though he drank little or
nothing at the time. In a day or two after he walked to some
distance.
1 2th Day. Pot. purgans illico.
14th Day. Pot. purg. c. jalap, dr. ss. 41'is diebus. Inf us. Dig.
Jtiis diebus.
(p- * 55 ) I 7 t h Day. R. Gamb. gr. Hi. calom. gr. ii. camph. gr. i.
syr. simpl.fiat pil. 0. n. sum. Inf us. Digit, j tiis diebus.
21st Day. Made an out-patient. The superabundant flow
of urine continued for the first three days after his last course;
but since, the flow of saliva has been nearly equal to that of
rhe smalls of his legs not quite reduced, and are fuller at night.
He has shrunk round the middle from four feet two inches to
The Foxglove 413
three feet six inches; and in the calves of his legs, from seventeen
inches to thirteen and a half.*
Obs. The waters were here very successfully evacuated, but
as you remarked to me, on communicating the case to you at the
time, tonic medicines should have been given, to second the
ground that had been gained, instead of weakening the patient
by drastic purgatives.
(p. 156) A Case from Mr. Shaw, Surgeon, at Stourbridge. —
Communicated by Doctor Stokes.
Matth. D , Aet. 71. Tall and thin. Disease a general
anasarca, with great difficulty of breathing. The lac ammoniac,
somewhat relieved his breath; but the swellings increased, and
his urine was not augmented. I considered it as a lost case, but
having seen the good effects of the Digitalis, as ordered by Dr.
Stokes in the case of Mrs. G , I gave him one spoonful of an
infusion of oz. ii. to half a pint, twice a day. His breath became
much easier, his urine increased considerably, and the swellings
gradually disappeared; since which his health has been pretty
good, except that about three weeks ago, he had a slight dysp-
noea, with pain in his stomach, which were soon removed by a
repetition of the same medicine.
Mr. Shaw likewise informs me, that he has removed pains in
the stomach and bowels, by giving a spoonful of the infusion,
dr. iss. to oz. viii. morning and night.
(p. 157) A Letter from Mr. Vaux, Surgeon, in Birmingham
Dear Sir,
I Send you the two following cases, wherein the- Digitalis had
very powerful and sensible effects, in the cure of the different
patients.
* In the three last recited cases, the medicine was directed in doses quite too strong,
and repeated too frequently. If Esther K could have survived the extreme sickness,
the diuretic effects would probably have taken place, and, from her time of life, I should
have expected a recovery. Wm. T seems to have been a bad case, and I think would
not have been cured under any management. G. R certainly possessed a good con-
stitution, or he must have shared the fate of the other two.
414
Medical Classics
Case I
Mrs. O of L Street, in this town, aged 28, naturally
of a thin, spare habit, and her family inclinable to phthisis, sent
for me on the nth of June, 1779 ? ^ "which time she complained
of great pain in her side, a constant cough, expectorated much,
which sunk in water; had colliquative sweats and frequent purg-
ing stools; the lower extremities and belly full of water, and from
the great difficulty she had in breathing, I concluded there was
water in the chest also. The quantity of water made at a time
for three weeks before I saw her, never amounted to more than
a tea-cup full, frequently not so much. Finding her in so alarm-
ing a situation, I gave it as my opinion she could receive no bene-
fit from medicine, and requested her not to take any; but she
being very desirous of my ordering her something, I complied,
and sent her a box of gum pills with squills, and a mixture with
salt of tartar: these medicines she took until the sixteenth, with-
out any good effects: the water in her legs now began to exsude
(p. 158) through the skin, and a small blister on one of her legs
broke. Believing she could not exist much longer, unless an
evacuation of the water could be procured; after fully informing
her of her situation, and the uncertainty of her surviving the use
of the medicine, I ventured to propose her taking the Digitalis,
which she chearfully agreed to. I accordingly sent her a pint
mixture, made as under, of the fresh leaves of the Digitalis.
Three drams infused in one pint of boiling water, when cold
strained off, without pressing the leaves, and two ounces of the
strong juniper water added to it: of this mixture she was ordered
four table spoonfulls every third hour, till it either made her sick,
purged her, or had a sensible effect on the kidneys. This mix-
ture was sent on the seventeenth, and she began taking it at noon
on the eighteenth. At one o’clock the following morning I was
called up, and informed she was dying. I immediately attended
her, and was agreeably surprised to find their fright arose from
her having fainted, in consequence of the sudden loss of twelve
quarts of water she had made in about two hours. I immedi-
ately applied a roller round her belly, and, as soon as they could
be made, 2 others, which were carried from the toes quite up to
The Foxglove 415
the thighs. The relief afforded by these was immediate; but
the medicine now began to affect her stomach so much, that she
kept nothing- on it many minutes together. I ordered her to
drink freely of beef tea, which she did, but kept it on her stomach
but a very short time. A neutral draught in a state of efferves-
cence was taken to no good purpose: She therefore continued
(p. 159) the beef tea, and took no other medicine for five days,
when her sickness went off: her cough abated, but the pain in
her side still continuing, I applied a blister which had the desired
effect: her urine after the first day flowed naturally. Her cure
was compleated by the gum pills with steel and the bitter in-
fusion. It must be observed she never had any collection of
water afterwards.
It affords me great pleasure to inform you that she is now liv-
ing, and has since had four children; all of whom, I think I may
justly say, are indebted to the Digitalis for their existence.
There appears in this case a striking proof of the utility of
emetics in some kinds of consumptions, as it appears to me the
dropsy was brought on by the cough, &c. and I believe these were
cured by the continual vomitings, occasioned by the medicine.
Case II
Mr. H , a publican, aged about 48 years, sent for me in
March, 1778- He complained of a cough, shortness of breathing,
which prevented him from laying down in bed; his belly, thighs
and legs very much distended with water; the quantity of urine
made at a time seldom exceeded a spoonful. I requested him to
get some of the Digitalis, and as they had no proper weights in
the house, I told them to put as much of the fresh leaves as would
•weigh down a guinea, into half a pint of boiling water; (p. 160)
to let it stand till cold, then to pour off the clear liquor, and add a
glass of gin to it, and to take three table spoonfuls every third
hour, until it had some sensible effect upon him.
Before he had taken all the infusion, the quantity of urine
made increased, (he therefore left off taking it), and it continued
to do so until all the w'ater was evacuated. His breathing became
much better, his cough abated, though it never quite left him;
4x6 Medical Classics
he being for some time before asthmatic. By taking some tonic
pills he continued quite well until the next spring, when he had a
return of his complaint, which was earned off by the same means.
Two years after, he had a third attack, and this also gave way to
the medicine. Last year he died of a pleurisy.
I am, &c.
Moor-Street, 8th May, Jer. Vaux.
i7 8 5*
P. S. You must well recollect the case of Mrs. F. . — It was
“a general dropsy — every time she took the medicine its effects
were similar, viz. The discharge of urine came on gradually
at first, increased afterwards, and the whole of the water both
in the belly, legs, &c. was perfectly evacuated. Although the
effects were only temporary, they were exceedingly agreeable to
the patient, making her time much more comfortable .” — ( See
Case XLIII.)
(p. 161) A Letter from Mr. Wainwright, Surgeon, in
Dudley
Dear Sir,
It gives me great pleasure to find you intend to publish your
observations on the Digitalis purpurea.
Several years are now elapsed since you communicated to me
the high opinion you entertained of the diuretic qualities of this
noble plant. To ensure success, due attention was recommended
to its preparation, its dose, and its effects upon the system.
I always gave the infusion of the dried leaves; the dose the
same as in the prescriptions returned. If the medicine operated
on the stomach or bowels, it was thought prudent to forbear.
When the kidneys began to perform their proper functions, and
the urine to be discharged, a continuance of its farther use was
unnecessary.
These remarks you made in the case of the first patient for
whom you prescribed the Digitalis in our neighbourhood, and I
have found them all necessary at this present period. From the
ecided good effects that followed from its use, in those cases
W . ere , most powerful remedies had failed, I was soon con-
vince it was a most valuable addition to the materia medica.
The Foxglove 417
(p. 162) The want of a certain diuretic, has long been one of
the desiderata of medicine. The Digitalis is undoubtedly at the
head of this class, and will seldom, if properly administered,
disappoint the expectation. I can speak with the more con-
fidence, having, in an extensive practice, been a happy witness
to its good qualities.
For several years, I have given the infusion in a variety of
cases, where there was a deficiency in the secretion of the urine,
with the greatest success. In recent obstructions, I do not recol-
lect many failures. In anasarcous diseases, and in the anasarca,
when combined with the ascites; in swellings of the limbs, and
in diseases of the chest, when there was the greatest reason to
believe an accumulation of serum, the most beneficial con-
sequences have followed from its use.
Had I been earlier acquainted with your intention to publish
an account of the Digitalis, I could have transmitted some cases,
which might have served to corroborate these assertions: but I
am convinced the Digitalis needs not my assistance to procure a
favorable reception. Its own merit will ensure success, more than
a hundred recited cases.
I could wish those gentlemen who intend to make use of this
plant, to collect it in a hot dry day, when the petals fall, and the
seed-vessels begin to swell.
(p. 163) The leaves kept to the second year are weaker, and
their diuretic qualities much diminished. It will therefore be
necessary to gather the plant fresh every season.
These cautions are unnecessary to the accurate botanist, who
well knows, that a plant in the spring, though more succulent
and full of juices, is destitute of those qualities which may be
expected when that plant has attained its full vigour, and the
seed-vessels begin to be manifest. But for want of attention to
these particulars, its virtues may be thought exaggerated, or
doubtful, if beneficial consequences do not always flow from its
use. There are diseases it cannot cure; and in several of those
patients in this town, who first took the Digitalis by your orders,
there was the most positive proof of the viscera being unsound.
In these desperate cases it often procured a plentiful flow of
urine, and palliated a disease which medicine could not remove.
4i 8 Medical Classics
At a remote distance, physicians are seldom applied to for
advice in trifling disorders. Many remedies have been tried
without relief, and the disease is generally obstinate or confirmed.
—It would not be fair to try the merits of the Digitalis on this
scale. It might often fail of promoting the end desired. I
flatter myself the reputation of this plant will be equal to its
merit, and that it will meet with a candid reception.
(p. 164) As there is no pleasure equal to relieving the miseries
and distresses of our fellow-creatures, I hope you will long enjoy
that peculiar felicity.
Permit me to return my thankful acknowledgments, for your
free communication of a medicine, by which means, through the
blessing of providence, I have been enabled to restore health and
happiness to many miserable objects.
I am, &c.
Yours,
J. Wainwright.
Dudley, April 26th,
1785.
Case of Mr. Ward, Surgeon, in Birmingham. — Related by
himself
In September , 178a, I was seized with a difficulty of breathing,
and oppression in my chest, in consequence of taking cold from
being called out in the night. My tongue was foul; my urine
small in quantity; my breath laborious and distressing on the
slightest exercise. I tried the medicines most generally recom-
mended, such as emetics, blisters, lac ammoniacum, oxymel of
squills, &c. but finding little or no relief, I consulted Dr. Wither-
ing, who advised me to try the following prescription.
(p. 165) R. Sol. Digital, purp. siccat. dr. iss.
Aq. bullientis oz. iv.
Aq. cinn. sp. oz. ss. digere per horas quatuor, et colaturae
capiat cochlear, i. nocte maneque.
He also desired me to take fifty drops of tincture of can-
thandes three or four times a day.
After taking eight ounces of the infusion, and about twelve
The Foxglove 419
drams of the drops, I was perfectly cured, and have had no return
since. The medicine did not occasion sickness or vertigo, nor
had they any other sensible effect than in changing the appear-
ance, and increasing the quantity of the urine, and rendering the
tongue clean. After the last dose or two indeed, I had a little
nausea, which was immediately removed by a small glass of
brandy.
Birmingham, 1st July, 1785.
Communications from Mr. Yonge, Surgeon, in Shiffnall,
Shropshire
Dear Sir,
I Have great satisfaction in complying with your just claim,
by transcribing outlines of the subsequent cases, for insertion
in your long requested tract on the Digitalis purpurea. The
two first of these you will easily recollect, the cures having been
conducted immediately upon your own management, (p. 166)
and the whole may add to that weight of evidence which long
experience enables you to adduce to the efficacy of that valuable
medicine. I have recited the only instances of its failure which
occur to me, but many other, though successful cases, wherein
its utility might seem dubious, and also the accounts received
from people whose accuracy might be suspected, I shall not for
obvious reasons trouble you with.
I am, dear Sir,
Your obliged friend,
William Yonge.
Shiffnal,
May 1, 1785.
Case I
A Gentleman aged 49, on the night of the 21st of August,
1784, awaked with a sense of suffocation, which obliged him to
rise up suddenly in bed. I found him complaining of difficult
respiration, particularly on lying down; the countenance pale,
and the pulse smaller and quicker than usual. Some brandy and
water having been given, the symptoms gradually abated, so
^2 0 Medical Classics
that he slept in a half recumbent posture. The following day he
expressed a sense of anxiety and weight in the chest, attended by
quicker breathing upon motion of the body. That evening an
emetic of ipecacohana was given, and afterwards a draught, with
vitriolic aether (p. 167) and confect, card, aa dr. i. to be repeated
as the symptoms should require it. He continued to be affected
with slighter returns of the dyspnoea at irregular intervals, until
September 15th, when upon a more severe attack, the emetic
was repeated. He now recollected some slight pain in his arms
which had affected him previous to this last seizure, and v.'as dis-
posed to consider his complaint as rheumatic. Pills with gum
ammoniac, gum guaiac. and antimonial powder were directed,
with infus. amar. simpl. twice a day. The bowels were regulated
by aperient pills of pulv. jalap, aloes and sal. tartar, and dr. iss
balsam peruv. was given occasionally to alleviate the paroxysms
of dyspnoea.
From this period until the beginning of November, little
amendment or variation happened, except that respiration be-
came more permanently difficult, and particularly oppressed upon
motion, nor was it relieved by the expectoration of a mucous dis-
charge, which now increased considerably. Squills, musk, oh
succini, aether, with other medicines of the same kind, were now
used, but without success. The effects of opium and venaesec-
tion we re tried. The appetite diminished, and his sleep became
short and disturbed. He sometimes slept lying upon his back,
but generally upon his left side. The urine which had hitherto
been of good colour, and sufficient quantity, now became dimin-
ished, and lateritious; and the ancles oedematous.
(p. 168) On the 15th of November a blister was laid over the
sternum, and dr. iss. of oxymel scillitic. was given every eight
hours. 0 ' '
On the 18th, a more copious discharge of urine took place;
t e swelling of the feet soon disappeared, and the respiration be-
came gradually relieved.
*' t ' nct ; cant haridum twice a day in pyrmont water,
with pills of ammoniac, sal tartar, et extract, gentian, were sub-
stituted, but
The Foxglove 4.21
On the 7th of . December , from some symptoms of relapse, the
oxymel was used as before, and continued to be taken until the
27th, in doses as large as could be dispensed with on account of
the great nausea which attended its exhibition: The urine was
made in the quantity of four to five pints each day, during the
whole time; the quantity then drank being seldom more than
three pints. But now the sickness being exceedingly depressing,
the strength failing, and the diuretic effects beginning to cease,
the following prescription was directed.
R. Sol. Digitalis purpur. pulv. scruples ss.
Spec. Aromatic, scruples i. sp. lav. c. f. pilul. no. x. capiat
i. nocte maneque, et alternis diebus sensim augeatur dosin.
In three days the effect of this medicine became visible, and
when the dose of the Digitalis had been (p. 169) increased to six
grains per day, the flow of urine generally amounted to seven
pints every twenty-four hours. Not the least sickness, nor any
other disagreeable symptom supervened, though he persevered
in this plan until the end of January at which time the dyspnoea
was removed, and he has continued gradually to regain his flesh,
strength, and appetite, without any relapse.
Case II
About the middle of the year 1784 a lady aged 48, returned
from London, to her native air in Shropshire, under symptoms of
complicated disease. It was your opinion that the plethoric
state, consequent to that period, when menstruation first begins
to cease, had under various appearances, laid the foundation of
that deplorable state which now presented itself. The skin was
universally of a pale, leaden colour; her person much emaciated,
and her strength so reduced, as to disable her from walking with-
out support. The appetite fluctuating, the digestion impaired
so much, that solids passed the intestines with little appearance
of solution: She had generally eight or ten alvine evacuations
even' day, and without this number, febrile symptoms, attended
with severe vertiginous affection, and vomiting regularly ensued.
The stools were of a pale ash colour. The urine generally pale,
and at first in due quantity. The region of the stomach (p. 170)
422 Medical Classics
had a tense feel, without soreness: the feet and ancles oedematousj
her sleep was uncertain: the pulse varying between 94 and 100
and feeble, except upon the approach of the menstrual periods,
which were now only marked by its increased strength, and ex-
acerbation of other febrile symptoms. Emetics, saline medicines,
and gentle aperients were necessary to alleviate these. Six
grains of ipecac operated with sufficient power, and half a grain
of calomel would have purged with great violence.
From the time of her arrival till the middle of August , mercury
had been continued in various forms, and in doses such as the
irritable state of her stomach and bowels would admit of. Spirit,
nitri dulc.; sal. tartar, squill, and cantharides were alternately
employed as diuretics, but without success, to retard the progress
of an universal anasarca, which was then advanced to such degree
and accompanied by so great debility, and other dreadful con-
comitants, as to threaten a speedy and fatal catastrophe.
On the 1 6th of August you first saw her, and directed thus.
R. Mercur. dnerei gr. ii.
Sol Digital, purpur. pulv. scruples i. f. mass, in pill. no.
xvi. dividend. — sumat unam hora meridiana, iterumque hora
quinta pomeridiana quotidie.
(p. 171) Capiat lixivii saponac. gutt. L. in haust. juscul. sine
sale parati omni nocte.
On the 20th the flow of urine began to increase, and she con-
tinued the medicine in the same dose until the 20th of September,
discharging from six to eight pints of water each day for the first
week, and which quantity gradually diminished as she became
empty. During this period she complained not of any sickness,
except from the lixivium, which was after the first dose reduced
to 20 drops; and her appetite and strength increased daily, though
it was evident that no bile had yet flowed into the bowels, nor
was the digestion at all improved. The anasarcous appearances
eing then removed, the Digitalis was omitted, and pills, com-
posed of mercur. cinereus, aloes, and sal tartari directed twice a
day, with dr. i. of vin. chalybeat. in infus. amar. simpl.
er amendment in other respects proceeded slowly, but regu-
arly, from that time until the 9th of October; when the state
The Foxglove 423
of plethora again recurring, with its usual attendant symptoms,
oz. i v. of blood were taken from the arm ; and this was upon the
same occasion, repeated in the following month, with manifest
good consequences; though in both instances the colour of the
blood, as flowing from the vein could hardly be called red, and
the coagulum was as weak in its cohesion as possible. The state
of the stomach and bowels was by this time greatly improved, in
common with other parts of (p. 172) the system; but no intro-
mission of bile had yet happened: the hardness about the hypo-
gastric region, though less, continued in a considerable degree,
and you ordered pills of mercury rubbed down, and rust of iron,
to be taken twice a day, with a decoction of dandelion and sal
sodae.
A cataplasm of linseed was applied every night over the stom-
ach and right side; and, with little deviation from this plan, she
continued to the end of the year, improving in her general health,
but the hepatic affection yet remaining. It was then determined
to try the effects of electricity, and gentle shocks were passed
through the body daily, and as nearly as could be through the
liver, in various directions.
On the fifth day there was reason to think that some gall had
been secreted and poured out, and this became every day more
evident; but it flowed only in small quantity, and irregularly into
the bowels, as appeared from the faeces being partially tinged by
it.
In February the lady left this neighbourhood, and though con-
valescent, yet so nearly well as to promise us the satisfaction of
seeing her perfectly restored.
June 29. The bile is now secreted in pretty good quantity,
her appetite is perfectly good, her strength equal to almost any
degree of exercise, and her (p. 173) health in general better than
it has been for some years.
Case III
Mr. W , aged — . In June , 1782, was affected with slight
difficulty in respiration, upon taking exercise or lying down in
bed. These symptoms increased gradually until the end of
424 Medical Classics
'July, -when he complained of sense of weight and uneasiness
about the proecordia; loss of appetite; and costiveness. The
urine was small in quantity, and high coloured; his pulse feeble,
and intermitting; he breathed with difficulty when in bed, and
slept little. After the exhibition of an emetic, and an opening
medicine of rhubarb, sena, and sal tartari, he was directed to
take half a dram of squill pill, pharm. Edinburg, night and morn-
ing, with dr. ss sal. sodae in oz. iss. infus. amar. simpl. twice a
day; and these medicines were continued during ten days, with-
out any sensible effect. A blister was then applied to the ster-
num, and six grains of calomel given in the evening. The symp-
toms were now increased very considerably, in every particular;
and the following infusion was substituted for the former medi-
cines.
R. Fol. Digital, purpur. dr. iii.
Cort. limon. dr. ii. infund.
Aq. bullient. lb. i. per hor. 2 et cola, sumat cochl. i. promo
mane et repet. omni hora.
(p. 174) Sometime in the night considerable nausea occurred,
and the following day he began to make water in great quantity,
which he continued to do for three or four days. The pulse in a
few hours became regular, slower, and stronger, and, in the course
of a wee k, all the symptoms entirely vanished, and an electuary
of cort. peruvian, sal martis, and spec, aromatic, confirmed his
cure.
In February, 1784, this gentleman had a relapse of his disease,
from which he again soon recovered by the same means, and is
now perfectly well.
Case IF
^ 5 ® husbandman, aged 57 - Was in the year 1782
affected with a slight, but constant pain in his breast, with diffi-
cult respiration. His countenance was yellow; the abdomen
swelled, and hard; his urine high coloured, and in small quantity;
appetite and sleep little. Complained of frequent nausea and
of sudden profuse sweatings, which seemed for a short time to
relieve the dyspnoea.
The Foxglove 425
After the exhibition of an emetic, six grains of calomel were
given, with a purge of jalap in the morning, and repeated in a few
days, with some appearance of advantage. He was then directed
to take some pills of squill, soap, and rhubarb, with a draught
twice a day, consisting of infus. amar. simp, and sal tartari. The
skin soon became clearer and (p. 175) the pain in his breast con-
siderably diminished. But every other circumstance remaining
the same, and a fluctuation in the belly being now more evident,
the infusion of digitalis as prescribed in case third, was given in
the dose of one ounce twice a day.
On the 5th day the effects were apparent, and he continued his
medicine for a fortnight without nausea, making four or five pints
of water every night, but little in the day, and gradually losing
the symptoms of his disease.
In 1784, this person had a relapse, and was again cured by
similar treatment.
Case V
R H , Aged 43. Towards the end of the year 1783,
became affected with slight cough and expectoration of purulent
matter. In December his skin became universally of a pale
yellow colour. The abdomen was swelled and hard; his appetite
little, and he complained of a violent and constant palpitation
of the heart, which prevented him from sleeping. The urine
pale, and in small quantity. The pulse exceedingly strong, and
rebounding; beating 114 to 120 strokes every minute. He
suffered violent pain of his head, and was very feeble and emaci-
ated. After bleeding, and the use of gentle aperient medicines,
he continued to take the infusion of Digitalis for some days, with-
out any sensible effect. Other diuretics were tried to as little
purpose (p. 176). Repeated bleeding had no effect in diminishing
the violent action of the heart. He died in January following,
under complicated symptoms of phthisis and ascites.
Case VI
A man aged 57, who. had lived freely in the summer of 1784,
became affected with oedematous swelling of his legs, for which
4_ 2 6 Medical Classics
he was advised to drink Fox Glove Tea. He took a four ounce
bason of the infusion made strong with the green leaves, every
morning for four successive days.
On the 5th he was suddenly seized with faintness and cold
sweatings. I found him with a pale countenance, complaining
of weakness, and of pain, with a sense of great heat in his stomach
and bowels. The swelling of the legs was entirely gone, he hav
ing evacuated urine in very large quantities for the two preceding
days. He was affected with frequent diarrhoea. The pulse
was very quick and small, and his extremities cold.
A small quantity of broth was directed to be given him every
half hour, and blisters were applied to the ancles, by which his
symptoms became gradually alleviated, and he recovered per-
fectly in the space of three weeks; except a relapse of the ana-
sarca, for which the Digitalis was afterwards successfully em-
ployed, in small doses, without any disagreeable consequence.
(p. 177) Case VII
S D , a middle aged single woman, was affected in the
year eighty-one, with a painful rigidity and slight inflammation
of the integuments on the left side, extending from the ear to
the shoulder. In every other particular she was healthy. The
use of warm fomentations, and opium, with two or three doses
of mercurial physic, afforded her ease and the inflammation dis-
appeared, but was succeeded by an oedematous swelling of the
part, which very gradually extended along the arm, and down-
ward to the breast, back, and belly. Friction, electricity and
mercurial ointment were amongst the number of applications
unsuccessfully employed to relieve her for the space of three
months, during which time she continued in good general health.
In November she became ascitic, passing small quantities of
urine, and soon afterwards a sudden dyspnoea gave occasion to
suppose an effusion of water in the thorax. The Digitalis, squills,
and cantharides were given in very considerable doses without
effect. She died the latter end of December following.
The Foxglove 427
Case Fill
W C , a collier aged 58, was attacked in the spring
of 1783 with tertian ague, which he attributed to cold, by sleeping
in a coal (p. 178) pit, and from which he recovered in a few days,
except a swelling of the lower extremities, which had appeared
about that time, and gradually increased for two or three months.
The legs and thighs were greatly enlarged and oedematous. His
belly was swelled, but no fluctuation perceptible. He made
small quantities of high coloured water. The appetite bad, and
pulse feeble. He had taken many medicines without relief, and
was now so reduced in strength, as to sit up with difficulty. An
infusion of the Digitalis was directed for him, in the proportion
of one ounce of the fresh leaves to a pint of water, two ounces to
be taken three times a day, until the stomach or bowels became
affected. Upon the exhibition of the sixth dose, nausea super-
vened, and continued to oppress him at intervals for two or three
days, during which he passed large quantities of pale urine. The
swelling, assisted by moderate bandage rapidly diminished, and
without any repetition of his medicine, at the expiration of six-
teen days, he returned to his labour perfectly recovered.
(p. 179) OF THE PREPARATIONS AND DOSES, OF THE FOXGLOVE
Every part of the plant has more or less of the same bitter
taste, varying, however, as to strength, and changing with the
age of the plant and the season of the year.
Root. — This varies greatly with the age of the plant. When
the stem has shot up for flowering, which it does the second year
of its growth, the root becomes dry, nearly tasteless, and inert.
Some practitioners, who have used the root, and been so happy
as to cure their patients without exciting sickness, have been
pleased to communicate the circumstance to me as an improve-
ment in the use of the plant. I have no doubt of the truth of
their remarks, and I thank them. But the case of Dr. Cawley
puts this matter beyond dispute. The fact is, they have fortun-
ately happened to use the root in its approach to its inert state,
and consequently have not over dosed their patients. I could.
428 Medical Classics
(p. 180) if necessary, bring other proof to shew that the root is
just as capable as the leaves, of exciting nausea.
Stem. — The stem has more taste than, the root has, in the
season the stem shoots out, and less taste than the leaves. I do
not know that it has been particularly selected for use.
Leaves— These vary greatly in their efficacy at different
seasons of the year, and, perhaps, at different stages of their
growth; but I am not certain that this variation keeps pace with
the greater or lesser intensity of their bitter taste.
Some who have been habituated to the use of the recent leaves,
tell me, that they answer their purpose at every season of the
year; and I believe them, notwithstanding I myself have found
very great variations in this respect. The solution of this
difficulty is obvious. They have used the leaves in such large
proportion, that the doses have been sufficient, or more than
sufficient, even in their most inefficacious state. ‘The Leaf-
stalks seem, in their sensible properties, to partake of an inter-
mediate state between the leaves and the stem.
Flowers. — The petals, the chives, and the pointal have nearly
the taste of the leaves, and it has been suggested to me, by a
very sensible and judicious friend, that it might be well to fix on
the flower for internal use. I see no objection to the proposition,
but I have not tried it.
(p. 181) Seeds. — These I believe are equally untried.
From this view of the different parts of the plant, it is suffi-
ciently obvious why I still continue to prefer the leaves.
These should be gathered after the flowering stem has shot up,
and about the time that the blossoms are coming forth.
The leaf-stalk and mid-rib of the leaves should be rejected,
and the remaining part should be dried, either in the sun-shine,
or on a tin pan or pewter dish before a fire.
If well dried, they readily rub down to a beautiful green powder,
which weighs something less than one-fifth of the original weight
of the leaves. Care must be taken that the leaves be not
scorched in drying, and they should not be dried more than what
is requisite to allow of their being readily reduced to powder.
I give to adults, from one to three grains of this powder twice a
The Foxglove 429
day. In the reduced state in which physicians generally find
dropsical patients, four grains a day are sufficient. I sometimes
give the powder alone; sometimes unite it with aromatics, and
sometimes form it into pills with a sufficient quantity of soap or
gum ammoniac.
If a liquid medicine be preferred, I order a dram of these dried
leaves to be infused for four hours in half a pint of boiling water,
adding to the strained liquor an ounce of any spirituous water.
One ounce of this infusion given twice a day, is a medium dose
for an adult patient. If the patient be stronger than usual, or
the symptoms very urgent, this dose may be given once in eight
hours; and on the contrary in many instances half an ounce at a
time will be quite sufficient. About thirty grains of the powder
or eight ounces of the infusion, may generally be taken before the
nausea commences.
The ingenuity of man has ever been fond of exerting itself to
vary the forms and combinations of medicines. Hence we have
spirituous, vinous, and acetous tinctures; extracts hard and soft,
syrups with sugar or honey, &c. but the more we multiply the
forms of any medicine, the longer we shall be in ascertaining its
real dose. I have no lasting objection however to any of these
formulae except the extract, which, from the nature of its prep-
aration must ever be uncertain in its effects; and a medicine
whose fullest dose in substance does not exceed three grains,
cannot be supposed to stand in need of condensation.
It appears from several of the cases, that when the Digitalis
is disposed to purge, opium may be joined with it advantageously;
and when the bowels are too tardy, jalap may be given at the
same time, (p. 183) without interfering with its diuretic effects;
but I have not found benefit from any other adjunct.
, From this view of the doses in which the Digitalis really ought
to be exhibited, and from the evidence of many of the cases, in
which it appears to have been given in quantities six, eight, ten
or even twelve times more than necessary, we must admit as an
inference either that this medicine is perfectly safe when given
as I advise, or that the medicines in daily use are highly
dangerous.
43 °
Medical Classics
(p. I84) EFFECTS, RULES, AND CAUTIONS
The Foxglove when given in very large and quickly-repeated
doses, occasions sickness, vomiting, purging, giddiness, confused
vision, objects appearing green or yellow; increased secretion of
urine, with frequent motions to part with it, and sometimes in-
ability to retain it; slow pulse, even as slow as 35 in a minute,
cold sweats, convulsions, syncope, death.*
When given in a less violent manner, it produces most of these
effects in a lower degree; and it is curious to observe, that the
sickness, with a certain dose of the medicine, does not take place
for many hours after its exhibition has been discontinued; that
the flow of urine will often precede, sometimes accompany, fre-
quently follow r the sickness at the distance of some days, and not
unfrequently be checked by it. The sickness thus excited, is
extremely different from that occasioned by any other medicine;
it is peculiarly distressing to the patient; it ceases, it recurs again
as violent as before; and thus it will continue to recur for three
or four days, at distant and more distant intervals.
(p. 185) These sufferings of the patient are generally rewarded
by a return of appetite, much greater than what existed before
taking the medicine.
But these sufferings are not at all necessary ; they are the effects
of our inexperience, and would in similar circumstances, more or
less attend the exhibition of almost every active and powerful
medicine we use.
Perhaps the reader will better understand how it ought to be
given, from the following detail of my own improvement, than
from precepts peremptorily delivered, and their source veiled
in obscurity.
At first I thought it necessary to bring on and continue the sick-
ness, in order to ensure the diuretic effects.
I soon learnt that the nausea being once excited, it was un-
necessary to repeat the medicine, as it was certain to recur fre-
quently, at intervals more or less distant.
*1 am doubtful whether it does not sometimes excite a copious flow of saliva.— See
cases at pages 115, 154, and 155.
The Foxglove 4.31
Therefore my patients were ordered to persist until the nausea
came on , and then to stop. But it soon appeared that the diuretic
effects would often take place first, and sometimes be checked
when the sickness or a purging supervened.
(p. 186) The direction was therefore enlarged thus — Continue
the medicine until the urine flows , or sickness or purging take place.
I found myself safe under this regulation for two or three years;
but at length cases occurred in which the pulse would be retarded
to an alarming degree, without any other preceding effect.
The directions therefore required an additional attention to
the state of the pulse, and it was moreover of consequence not to
repeat the doses too quickly, but to allow sufficient time for the
effects of each to take place, as it was found very possible to pour
in an injurious quantity of the medicine, before any of the signals
for forbearance appeared.
Let the medicine therefore be given in the doses , and at the intervals
mentionea above: — let it be continued until it either acts on the kid-
neys , the stomach , the pulse , or the bowels; let it be stopped upon the
first appearance of any one of these effects , and I will maintain that
the patient will not suffer from its exhibition, nor the practitioner
be disappointed in any reasonable expectation.
If it purges, it seldom succeeds well.
The patients should be enjoined to drink very freely during
its operation. I mean, they should drink whatever they prefer,
and in as great quantity (p. 187) as their appetite for drink de-
mands. This direction is the more necessary, as they are very
generally prepossessed with an idea of drying up a dropsy, by
abstinence from liquids, and fear to add to the disease, by indulg-
ing their inclination to drink.
In cases of ascites and anasarca; when the patients are weak,
and the evacuation of the water rapid; the use of proper bandage
is indispensably necessary to their safety.
If the water should not be wholly evacuated, it is best to allow
an interval of several days before the medicine be repeated, that
food and tonics may be administered; but truth compels me to
say, that the usual tonic medicines have in these cases very often
deceived my expectations.
43 2 Medical Classics
From some cases which have occurred in the course of the
present year, I am disposed to believe that the Digitalis may be
given in small doses, viz. two or three grains a day, so as gradually
to remove a dropsy, without any other than mild diuretic effects,
and without any interruption to its use until the cure be corn-
pleated.
If inadvertently the doses of the Foxglove should be prescribed
too largely, exhibited too rapidly, or urged to too great a length;
the knowledge of a remedy to counteract its effects would be a
desirable (p. 18S) thing. Such a remedy may perhaps in time
be discovered. The usual cordials and volatiles are generally
rejected from the stomach; aromatics and strong bitters are
longer retained; brandy will sometimes remove the sickness when
only slight; I have sometimes thought small doses of opium useful,
but I am more confident of the advantage of blisters. Mr.
Jones {Page 135) in one case, found mint tea to be retained longer
than other things.
(p. 189) CONSTITUTION OF PATIENTS
Independent of the degree of disease, or of the strength or age
of the patient, I have had occasion to remark, that there are
certain constitutions favourable, and others unfavourable to the
success of the Digitalis.
From large experience, and attentive observation, I am pretty
well enabled to decide a priori on this matter, and I wish to enable
others to do the same: but I feel myself hardly equal to the under-
taking. The following hints, however, aiding a degree of ex-
perience in others, may lead them to accomplish what I yet can
describe but imperfectly.
It seldom succeeds in men of great natural strength, of tense
fibre, of warm skin, of florid complexion, or in those with a tight
and cordy pulse.
If the belly in ascites be tense, hard, and circumscribed, or the
limbs in anasarca solid and resisting, we have but little to hope.
On the contrary, if the pulse be feeble or intermitting, the
countenance pale, the lips livid, the skin cold, the swollen belly
soft and fluctuating, or (p. 190) the anasarcous limbs readily
The Foxglove 433
pitting under the pressure of the finger, we may expect the diu-
retic effects to follow in a kindly manner.
In cases which foil every attempt at relief, I have been aiming,
for some time past, to make such a change in the constitution of
the patient, as might give a chance of success to the Digitalis.
By blood-letting, by neutral salts, by chrystals of tartar,
squills, and occasional purging, I have succeeded, though imper-
fectly. Next to the use of the lancet, I think nothing lowers the
tone of the system more effectually than the squill, and conse-
quently it will always be proper, in such cases, to use the squill;
for if that .fail in its desired effect, it is one of the best prepara-
tives to the adoption of the Digitalis.
A tendency to paralytic affections, or a stroke of the palsy
having actually taken place, is no objection to the use of the
Digitalis; neither does a stone existing in the bladder forbid its
use. Theoretical ideas of sedative effects in the former, and
apprehensions of its excitement of the urinary organs in the latter
case, might operate so as to make us withhold relief from the
patient; but experience tells me, that such apprehensions are
groundless.
(p. 191) INFERENCES
To prevent any improper influence, which the above recitals
of the efficacy of the medicine, aided by the novelty of the sub-
ject, may have upon the minds of the younger part of my readers,
in raising their expectations to too high a pitch, I beg leave to
deduce a few inferences, which I apprehend the facts will fairly
support.
I. That the Digitalis will not universally act as a diuretic.
II. That it does do so more generally than any other medicine.
III. That it will often produce this effect after every other
probable method has been fruitlessly tried.
IV. That if this fails, there is but little chance of any other
medicine succeeding.
V. That in proper doses, and under the management now
pointed out, it is mild in its operation, and gives less disturbance
to the system, than squill, or almost any other active medicine.
434 Medical Classics
VI. That when dropsy is attended by palsy, unsound viscera,
great debility, or other complication of disease, neither the
Digitalis, nor any other diuretic (p. 192) can do more than obtain
a truce to the urgency of the symptoms; unless by gaining time,
it may afford opportunity for other medicines to combat and
subdue the original disease.
VII. That the Digitalis may be used with advantage in every
species of dropsy, except the encysted.
VIII. That it may be made subservient to the cure of diseases,
unconnected with dropsy.
IX. That it has a power over the motion of the heart, to a
degree yet unobserved in any other medicine, and that this
power may be converted to salutary ends.
(p. I93) PRACTICAL REMARKS ON DROPSY AND SOME OTHER
DISEASES
The following remarks consist partly of matter of fact, and
partly of opinion. The former will be permanent; the latter
must vary with the detection of error, or the improvement of
knowledge. I hazard them with diffidence, and hope they will
be examined with candour; not by a contrast with other opinions,
but by an attentive comparison with the phoenomena of disease.
Anasarca
1. The anasarca is generally curable when seated in the sub-
cutaneous cellular membrane, or in the substance of the lungs.
2. When the abdominal viscera in general are greatly enlarged,
which they sometimes are, without effused fluid in the cavity of
the abdomen; the disease is incurable. After death, the more
solid viscera are found very large and pale. If the cavity con-
tains water, that water may be removed by diuretics.
(p. 194) 3. In swollen legs and thighs, where the resistance
to pressure is considerable, the tendency to transparency in the
skin not obvious, and where the alteration of posture occasions
but little alteration in the state of distension, the cure cannot be
effected by diuretics.
Is this difficulty of cure occasioned by spissitude in the effused
The Foxglove 435
fluids, by want of proper communication from cell to cell, or is
the disease rather caused by a morbid growth of the solids, than
by an accumulation of fluid?
Is not this disease in the limbs similar to that of the viscera (2) ?
4. Anasarcous swellings often take place in palsied limbs, in
arms as well as legs; so that the swelling does not depend merely
upon position.
5. Is there not cause to suspect that many dropsies originate
from paralytic affections of the lymphatic absorbents ? And if so,
is it not probable that the Digitalis, which is so effectual in re-
moving dropsy, may also be used advantageously in some kinds
of palsy?
Ascites
6. If existing alone, (i.e.) without accompanying anasarca, is
in children curable; in adults generally incurable by medicines.
Tapping may be (p. 195) used here with better chance for success
than in more complicated dropsies. Sometimes cured by vomit-
ing.
Ascites and anasarca
7. Incurable if dependent upon irremediably diseased viscera,
or on a gouty constitution, so debilitated, that the gouty par-
oxysms no longer continue to be formed.
In every other situation the disease yields to diuretics and
tonics.
Ascites , anasarca, and hydrothorax
8. Under this complication, though the symptoms admit of
relief, the restoration of the constitution can hardly be hoped for.
Asthma
9. The true spasmodic asthma, a rare disease — is not relieved
by Digitalis.
10. In the greater part of what are called asthmatical cases,
the real disease is anasarca of the lungs, and is generally cured
by diuretics. (See 1.) This is almost always combined with
some swelling of the legs.
436 Medical Classics
(p. 196) n. There is another kind of asthma, in which change
of posture does not much affect the patient. I believe it to be
caused by an infarction of the lungs. It is incurable by diuretics ;
but it is often accompanied with a degree of anasarca, and so
far it admits of relief.
Is not this disease similar to that in the limbs at (3.) and also
to that of the abdominal viscera at (a.) ?
Asthma and anasarca
12. If the asthma be of the kind mentioned at (9 and 1 1 ,)
diuretics can only remove the accompanying anasarca. But if
the affection of the breath depends also upon cellular effusion,
as it mostly does, the patient may be taught to expect a recovery.
Asthma and ascites
13. A RapvE combination, but not incurable if the abdominal
viscera are sound. The asthma is here most probably of the
anasarcous kind (10;) and this being seldom confined to the lungs
only, the disease generally appears in the following form.
(p. 197) Asthma , ascites , and anasarca
14. The curability of this combination will depend upon the
circumstances mentioned in the preceding section, taking also
into the account the strength or weakness of the patient.
«
Epilepsy
15. In epilepsy dependant upon effusion, the Digitalis will
effect a cure; and in the cases alluded to, the dropsical symptoms
are unequivocal. It has not had a sufficient trial in my hands, to
determine what it can do in other kinds of epilepsy.
Hydatid dropsy
16. This may be distinguished from common ascites, by the
want of evident fluctuation. It is common to both sexes. It
does not admit of a cure either by tapping or by medicine.
437
The Foxglove
Hydrocephalus
17. This disease, which has of late so much attracted the at-
tention of the medical world, I believe, originates in inflamma-
tion; and that the water found in the ventricles of the brain after
death, is the consequence, and not the cause of the illness.
It has seldom happened to me to be called upon in the earlier
stages of this complaint, and the symptoms (p. 198) are at first
so similar to those usually attendant upon dentition and worms,
that it is very difficult to pronounce decidedly upon the real
nature of the disease; and it is rather from the failure of the usual
modes of relief, than from any other more decided observation,
that we at length dare to give it a name.
At first, the febrile symptoms are sometimes so unsteady, that
I have known them mistaken for the symptoms of an intermit-
tent, and the cure attempted by the bark.
In the more advanced stages, the diagnostics obtrude them-
selves upon our notice, and put the situation of the patient be-
beyond a doubt. But this does not always happen. The varia-
tions of the pulse, so accurately described by the late Dr. Whytt,
do not always ensue. The dilatation of the pupils, the squinting,
and the aversion to light, do not universally exist. The scream-
ing upon raising the head from the pillow or the lap, and the
flushing of the cheeks, I once considered as affording indubitable
marks of the disease; but in a child which I sometime since at-
tended with Dr. Ash, the pulse was uniformly about 85, (except
during the first week, before we had the care of the patient).
The child never shewed any aversion to the light; never had
dilated pupils, never squinted, never screamed when raised from
the lap or taken out of the bed, nor did we observe any remark-
able flushing of the cheeks; and the sleep was quiet, but some-
times moaning.
(p. 199) Frequent vomiting existed from the first, but ceased
for several days towards the conclusion. One or two worms
came away during the illness, and it was all along difficult to
purge the child. Three days before death, the right side became
slightly paralytic, and the pupil of that eye somewhat dilated.
43 8 Medical Classics
After death, about two ounces and a half of water were found
in the ventricles of the brain, and the vessels of the dura mater
were turgid with blood.
If I am right as to the nature of hydrocephalus, that it is at
first dependant upon inflammation, or congestion; and that the
water in the ventricles is a consequence, and not a cause of the
disease; the curative intentions ought to be extremely different
in the first and the last stages.
It happens very rarely that I am called to patients at the begin-
ning, but in two instances wherein I was called at first, the
patients were cured by repeated topical bleedings, vomits, and
purges.
Some years ago I mentioned these opinions, and the success
of the practice resulting from them, to Dr. Quin, now physician
at Dublin. That gentleman had lately taken his degree, and
had chosen hydrocephalus for the subject of his thesis in the
year 1779. this very ingenious essay, which he gave me the
same morning, I was much pleased to find that the author had
not only held the same (p. 200 ) ideas relative to the nature of
the disease, but had also confirmed them by dissections.
In the year 1781, another case in the first stage demanded my
attention. The reader is referred back to Case LXIX for the
particulars.
I have not yet been able to determine whether the Digitalis
can or cannot be used with advantage in the second stage of the
hydrocephalus. In case XXXIII. the symptoms of death were
at hand; in Case LXIX. the practice, though successful, w r as too
complicated, and in Case CLI. the medicine was certainly stopped
too soon.
When we consider what enormous quantities of mercury may
be used in this complaint, without affecting the salivary glands,
it seems probable that other parts may be equally insensible to
the action of their peculiar stimuli, and therefore that the Digi-
talis ought to be given in much larger doses in this, than in other
diseases.
The Foxglove 439
Hydrothorax
18. Under this name I also include the dropsy of the peri-
cardium.
The intermitting pulse, and pain in the arms, sufficiently dis-
tinguish this disease from asthma, and from anasarcous lungs.
It is very universely cured by the Digitalis.
(p. 201) 19. I lately met with two cases which had been con-
sidered and treated as angina pectoris. They both appeared to
me to be cases of hydrothorax. One subject was a clergyman,
whose strength had been so compleatly exhausted by the con-
tinuance of the disease, and the attempts to relieve it, that he
did not survive many days. The other was a lady, whose time
of life made me suspect effusion. I directed her to take small
doses of the pulv. Digitalis, which in eight days removed all her
complaints. This happened six months ago, and she remains
perfectly well.
Hydrothorax and anasarca
20. This combination is very frequent, and, I believe, may
always be cured by the Digitalis.
21. Dropsies in the chest either with or without anasarcous
limbs, are much more curable than those of the belly. Probably
because the abdominal viscera are more frequently diseased in
the latter than in the former cases.
Insanity
22. I Apprehend this disease to be more frequently connected
with serous effusion than has been commonly imagined.
23. Where appearances of anasarca point out the true cause of
the complaint, as in cases XXIV. and (p. 202) XXXIV. the hap-
piest effects may be expected from the Digitalis; and men of more
experience than myself in cases of insanity, will probably employ
it successfully in other less obvious circumstances.
Nephritis calculosa
24. We have had sufficient evidence of the efficacy of the Fox-
glove in removing the Dysuria and other symptoms of this
440 Medical Classics
disease; but probably it is not in these cases preferable to the
tobacco.*
Ovarium dropsy
24 This species of encysted dropsy is not without difficulty
distinguishable from an ascites; and yet it is necessary to dis-
tinguish them, because the two diseases require different treat-
ment and because the probability of a cure is much greater in
one than in the other.
16. The ovarium dropsy is generally slow in its progress; for a
considerable time the patient though somewhat emaciated, does
not lose the appearance of health, and the urine flows in the usual
quantity. It is seldom that the practitioner is called in early
enough to distinguish by the feel on which side the cyst origi-
nated, and the patients do not attend to that circumstance them-
selves. They generally menstruate (p. 203) regularly in the
incipient state of the disease, and it is not until the pressure from
the sac becomes very great, that the urinary secretion diminishes.
In this species of dropsy, the patients, upon being questioned,
acknowledge even from a pretty early date, pains in the upper
and inner parts of the thighs, similar to those which women ex-
perience in a state of pregnancy. These pains are for a length
of time greater in one thigh than in the other, and I believe it will
be found that the disease originated on that side.
27. The ovarium dropsy defies the power of medicine. It
admits of relief, and sometimes of a cure, by tapping. I submit
to the consideration of practitioners, how far we may hope to
cure this disease by a seton or a caustic. — In the LXIst case the
patient was too much reduced, and the disease too far advanced
to allow of a cure by any method; but it teaches us that a caustic
may be used with safety.
28. When tapping becomes necessary, I always advise the
adoption of the waistcoat bandage or belt, invented by the late
very justly celebrated Dr. Monro, and described in the first
volume of the Medical Essays. I also enjoin my patients to
wear this bandage afterwards, from a persuasion that it retards
* See a « orf ginal and valuable treaties by Dr. Fowler, entitled, Medical Reports of the
Effects of Tobacco. r
The Foxglove 441
the return of the disease. The proper use of bandage, when the
disorder first discovers itself, certainly contributes much to pre-
vent its increase.
(p. 204) Ovarium dropsy with anasarca
29. The anasarca does not appear until the encysted dropsy
is very far advanced. It is then probably caused by weakness
and pressure. The Digitalis removes it for a time.
1 Phthisis pulmonalis
30. This is a very increasing malady in the present day. It
is no longer limited to the middle part of life: children at five
years of age die of it, and old people at sixty or seventy. It is
not confined to the flat-chested, the fair skinned, the blue eyed,
the light-haired, or the scrophulous: it often attacks people with
full chests, brown skins, dark hair and eyes, and those in whose
family no scrophulous taint can be traced. It is certainly in-
fectious. The very strict laws still existing in Italy to prevent
the infection from consumptive patients, were probably not
enacted originally without a sufficientc ause. We seem to be
approaching to that state which first made such restrictions neces-
sary, and in the further course of time, the disease will probably
fall off again, both in virulency and frequency.
31. The younger part of the female sex are liable to a disease
very much resembling a true consumption, and from which it is
difficult to distinguish it; but this disease is curable by steel and
bitters. A criterion of true phthisis has been sought for in the
(p. 205) state of the teeth; but the exceptions to that rule are
numerous. An unusual dilatation of the pupil of the eye, is the
most certain characteristic.*
32. Sydenham asserts, that the bark did not more certainly
* Many years ago I communicated to my friend, Dr. Perrival, an account of some
trials of breathing fixed air in consumptive cases. The results were published by him in
the second VoL of his very usefull Essays Medical and Experimental, and have since
been copied into other publications. I take this opportunity of acknowledging that I
Suspect myself to have been mistaken in the nature of the disease there mentioned to have
been cured. I believe it was a case of Vomica , and not a true Phthisis that was cured.
The Vomica is almost always curable. The fixed air corrects the smell of the matter,
and very shortly removes the hectic fever. My patients not only inspire it, but I keep
large jars of the effervescing mixture constantly at work in their chambers.
44.2 Medical Classics
cure an intermittent, than riding did a consumption. We must
not deny the truth of an assertion, from such authority, but we
must conclude that the disease was more easily curable a century
ago than it is at present.
33. If the Digitalis is no longer useful in consumptive cases,
it must be that I know not how to manage it, or that the disease
is more fatal than formerly; for it would be hard to deny the
testimony cited at page 9. I wish others would undertake the
enquiry.
34. When phthisis is accompanied with anasarca, or when there
is reason to suspect hydrothorax, the Digitalis will often relieve
the sufferings, and prolong the life of the patient.
(p. 206) 35. Many years ago, during an attendance upon Mr.
B , of a consumptive family, and himself in the last stage of a
phthisis; after he was so ill as to be confined to his chamber, his
breathing became so extremely difficult and distressing, that he
wished rather to die than to live, and urged me warmly to devise
some mode to relieve him. Suspecting serous effusion to be the
cause of this symptom, and he being a man of sense and resolu-
tion, I fully explained my ideas to him, and told him what kind
of operation might afford him a chance of relief; for I was then
but little acquainted with the Digitalis. He was earnest for the
operation to be tried, and with the assistance of Mr. Parrott, a
very respectable surgeon of this place, I got an opening made
between the ribs upon the lower and hinder part of the thorax.
About a pint of fluid was immediately discharged, and his breath
became easy. This fluid coagulated by heat.
After some days a copious purulent discharge issued from the
opening, his cough became less troublesome, his expectoration
less copious, his appetite and strength returned, he got abroad,
and the wound, which became very troublesome, was allowed to
heal.
He then undertook a journey to London; whilst there he be-
came worse: returned home, and died consumptive some weeks
afterwards.
443
The Foxglove
(p. 207) Puerperal anasarca
36. This disease admits of an easy and certain cure by the
Digitalis.
37. This species of dropsy may originate from other causes
than child birth. In the beginning of last March, a gentleman
at Wolverhampton desired my advice for very large and painful
swelled legs and thighs. He was a temperate man, not of a drop-
sical habit, had great pain in his groins, and attributed his com-
plaints to a fall from his horse. He had taken diuretics, and the
strongest drastic purgatives with very little benefit. Considering
the anasarca as caused by the diseased inguinal glands, I ordered
common poultice and mercurial ointment to the groins, three
grains of pulv. sol. Digitalis night and morning, and a cooling
diuretic decoction in the day-time. He soon lost his pain, and
the swellings gradually subsided.
THE END
MEDICAL CLASSICS
VOL. II
January, 193 8
no. 5
CONTENTS
Portrait of Reginald Heber Fitz - -- -- -- - 446
Reginald Heber Fitz
Biography - -- -- -- -- -- -- 447
Bibliography of Writings - -- -- -- - 448
Bibliography of Biographies ------- 453
Index to Bibliography - -- -- -- -- 454
Perforating Inflammation of the Vermiform Appen-
dix; with Special Reference to its Early Diag-
nosis and Treatment. Reginald H. Fitz - - - 459
Portrait of Charles McBurney - -- -- -- - 492
Charles McBurney
Biography - -- -- -- -- -- --493
Eponyms - -- -- -- -- -- -- 494
Bibliography of Writings - -- -- -- - 495
Bibliography of Biographies ------- 500
Index to Bibliography - -- -- -- -- 501
Experience with Early Operative Interference in Cases
of Disease of the Vermiform Appendix. 1889.
Charles McBurney, M.D. ------- - 506
The Incision Made in the Abdominal Wall in Cases
of Appendicitis, with a Description of a
New Method of Operating. 1894. Charles
McBurney, M.D. - -- -- -- -- - 533
MEDICAL CLASSICS
vol. ii January, 1938 no. 5
1S43
1864
1867
1868
1870
JS73
1878
1886
1887
1892
1905
1909
1 9 I 3
IS®
Reginald Heber Fitz
BIOGRAPHY
Born at Chelsea, Massachusetts. His father died young,
leaving a widow with six children to support. Educated
at the Chauncey Hall School.
Age 21. Graduated from Harvard College.
Age 24. Received an appointment as house officer at the
Boston City Hospital.
Age 25. Obtained the M.D. degree at Harvard and then
traveled in Europe, studied in Vienna with Rokitansky
and Skoda and in Berlin with Virchow.
Age 27. Returned to Boston and became an instructor
in microscopic pathology at the Harvard Medical
School.
Age 30. Became an assistant professor.
Age 35. Became professor of pathological anatomy at
Harvard and had charge of the pathological laboratory
at the Massachusetts General Hospital.
Age 43. Suggested the name appendicitis and made a
classic report on this disease.
Age 44. Became a visiting physician at the Massachu-
setts General Hospital.
Age 49. Became professor of medicine at Harvard,
occupying the Herseian Chair of the Theory and
Practice of Physic.
Age 62. Degree of LL.D. conferred on him by Harvard.
Age 63. Retired from professorship at Harvard Medical
School.
Age 70. Died.
.48 Medical Classics
Member of the Massachusetts Medical Society.
Member of the Boston Society for Medical Observation.
Member of the Boston Society for Medical Improvement.
Member of the Boston Society of Medical Sciences.
President of the Boylston Medical Society of Harvard
University.
Member and President in 1894 of the Association of Ameri-
can Physicians.
Member of the Interurban Club.
Member of the American Medical Association.
Member of the American Academy of Arts and Sciences.
BIBLIOGRAPHY OF WRITINGS
1. Belladonna versus opium. (Graduation thesis) Boston M.
& S. J., 79: 272-282; 289-297, 1868.
2. Multilocular encysted disease of the cellular tissue, recurrent
after operation. With H. J. Bigelow. Ibid., 84: 241-242,
1871.
3. Translation of “Ueber Lazarette und Baracken” by R. Vir-
chow. Ibid., 84: 260-262, 1871.
4. A case of double monstrosity — union upon the anterior
median line from clavicle to umbilicus. With H. 0.
Marcy. Ibid., 85: 17-20, 1871.
5. The theory of tuberculosis. A brief account of some of its
more important features. Mass. Med. Soc., 3: 173-200,
1871.
6. Examination and drawings of spindle-celled sarcoma of
choroid removed by operation. Boston M. & S. J., 86:
85-88, 1872.
7. Report on pathology and pathological anatomy. Ibid.,
88: 393~397; 416-41 8, 1873; 89: 379-383; 401-405, 1874;
90: 381-383; 400-403, 1874; 91: 375-377; 401-404, 1875;
92: 43S-443; 464-470, 1875; 93: 469-473; 496-503, 1875;
94: 446-450; 477-481, 1876; 95: 464-467; 492-496, 1876;
*' 434-440, 1877; 97: 555-559; 587-591, 1877;
98: 666-670; 695-698, 1878; 99: 653-656; 692-696, 1878;
100: 710-7x5; 744-748, 1879; loi: 729-734; 766-770, 1879.
Reginald Heber Fitz 449
8. Translation, with A. Van Hurlington & J. T. Whittaker, of
H. Sebert’s Relapsing fever, typhus fever and cholera.
Cyclop. Pract. Med. (Ziemssen), i, 1874.
9. Tubo-uterine and interstitial pregnancy. Am. J. M. Sc.,
n.s. 69: 95- 103, 1875.
10. Anatomy of the fasciola Jacksoni. New York M. T., 24:
513-518, 1876.
11. Rupture of the healthy esophagus. Am. J. M. Sc., n.s.
7 3 - 17 - 36 , 1877.
12. Sudden death from embolism. Boston M. & S. J., 96:
93-105, 1877.
13. The value of anatomical appearances. Tr. Massachusetts
Med.-Leg. Soc., 1: 14-24, 1878. Also: Boston M. & S.
J., 99: 168-178, 1878.
14. Fatal case of hydrophobia. Ibid., 201-268, 1878.
15. Revised F. C. Shattuck & G. K. Sabine’s translation of
S. Orth’s, A compend of diagnosis in pathological anatomy.
440 pp., 8°, Boston, Houghton, Osgood, 1878; 1879;
1880; 1882.
16. Diabetic coma; its relation to acetonaemia and fat embolism.
Boston M. & S. J., 104: 124-127; 132, 1881.
17. A case of hydrophobia of doubtful origin. By S. L. Abbot
and R. H. Fitz. Ibid., 147-150.
18. Diseases of the liver. Jaundice; cholecystotomy; hypertro-
phic cirrhoses. Cyclop. Pract. Med. (Ziemssen), N. Y.,
suppl., 467-473, 1881.
19. Persistent omphalo-mesenteric remains; their importance
in the causation of intestinal duplication, cyst-formation
and obstruction. Am. J. M. Sc., n.s. 88: 30-57, 1884.
20. The recent investigations concerning the etiology of cholera.
Boston M. & S. J., 1 12: 169-172; 196-199, 1885.
21. Localized amyloid degeneration; amyloid lymphoma? Ibid.,
114: 389-390, 1886.
22. Perforating inflammation of the vermiform appendix, with
special reference to its early diagnosis and treatment.
Tr. Assn. Am. Physicians, Phila., i: 107-144, 1886. Also:
Am. J. M. Sc., n.s. 92: 321— 346, 1886. Also, abstr.:
450 Medical Classics
Boston M. & S. J., 115: 1 13 only, 1886. Also, abstr.:
Ibid., 169: 616-617, 1913.
The origin of typhoid fever in hospitals, and the means
suggested for its prevention. Boston M. & S. J., 118:
513-516, 1888.
14. The relation of perforating inflammation of the vermiform
appendix to peri typhli ti c abscess. New York M. J., 47:
5°5-5°8, 1888.
15. The diagnosis and medical treatment of acute intestinal
obstruction. Boston M. & S. J., 119: 445-449; 469-471;
493“495? 52^3—52.8, 1888. Also: Tr. Cong. Am. Phys. &
Surg., 1888, 1: 1-41, 1889. Also: 64 pp., ii°, Boston,
Cupples & Hurd, 1889.
16. Acute pancreatitis: a consideration of pancreatic hemor-
rhage, hemorrhagic, suppurative, and gangrenous pan-
creatitis, and of disseminated fat-necrosis. Boston M. &
S. J., 110: 181-187; 105-107; 119-135, 1889. Also: Med.
Rec., N. Y., 35: 197-105; 115; 153, 1889. Also: Med.
News, 54: 197; 115; 156; 181 ; 309, 1889. Also: Proc.
New York Path. Soc. (1889), pp. 3-70, 1890.
17. Letter. Typhloenteritis and appendicitis. Boston M. &
S. J., 111: 167 only, 1890.
18. Acute pancreatitis. Report of a case and reference to recent
contributions. Ibid., ill: 571-575, 1890. Also: Tr.
Assn. Am. Physicians, 5: 1 91-100, 1890.
29. Appendicitis; some of the results of the analysis of seventy-
two cases seen in the past four years. Boston M. & S. J.,
ill: 619-620, 1890.
30. Henry Jacob Bigelow; a tribute of respect inspired by affec-
tion, admiration and obligation. Ibid., 123: 511-514, 1890.
31. Perforating gastric ulcer; circumscribed peritonitis; death
on the fifteenth day. Ibid., 123: 583 only, 1890.
32. Intestinal perforation in typhoid fever; its prognosis and
treatment. Tr. Assn. Am. Physicians, 6: 200-215, *891.
Also: Boston M. & S. J., 125: 346-348; 365-367, 1891.
33. A case of amoebic dysentery. By E. P. Gerry and R. H.
Fitz. Ibid., 125: 592, 1891.
Reginald Heber Fitz 4.51
34. The diagnosis and treatment of inflammation of the appen-
dix. A discussion, at the Annual Meeting of the Massa-
chusetts Medical Society, June 9, 1891.- Med. Com-
munications Mass. Med. Soc., 15: 536-537, 1891.
35. The pathology of pelvic inflammation. Boston M. & S.
J., 126: 491-493, 1892. Also: Am. Gynec. & Pcdiat., 5:
537-54°, 1892.
36. The four years’ course at the Harvard Medical School.
Boston M. & S. J., 126: 599-600, 1892.
37. Shall there be a four years’ course? Ibid., 127: 225, 1892.
38. Acute pancreatitis. Ibid., 127: 571-572, 1892. Also: Tr.
Rhode Island M. Soc., 4: 452, 1893.
39. Lectures on Pathology. From the shorthand notes of
Charles F. Allen, M.D. 3rd ed., Boston, MacDufFce &
Palmer, 1892. (1st two editions were made up of typed
or mimeographed sheets.)
40. The duties and dangers of the doctor’s life. Boston M. &
S.J., 128:303, 1893.
41. Intra-peritoneal hemorrhage. Tr. M. & Chir. Fac. Mary-
land, Balt., pp. 83-95, ^93* Also: Maryland M. J., 29:
155-163, 1893. Also: Boston M. 6c S. J., 128: 618-621,
1893.
42. The rise and fall of the licensed physician in Massachusetts,
1781-1860. Tr. Assn. Am. Physicians, 9: 1-18, 1894.
Also: J. A. M. A., 22: 877-883, 1894. Also: Boston M. &
S. J., 130: 529-534, 1894.
43. The legislative control of medical practice. Med. Communi-
cations Mass. Med. Soc., 16: 277-360, 1894. Also: Boston
M. 6c S. J., 130: 581-585; 609-613; 637-641; 131: 1-5;
25-27, 1894.
44. Diseases of the esophagus. In: Twentieth Cent. Pract.,
8°, N. Y., 8: 83-113, 1896.
45. The practice of medicine. By Horatio C. Wood and R. H.
Fitz. 8°, Philadelphia, London, 1897.
46. Pneumonia; broncho-pneumonia; chronic fibrous pneumonia.
Syst. Pract. M. (Loomis), 2: 197-225, 1897.
47. Diabetes mellitus; with especial reference to its pancreatic
4^2 Medical Classics
origin and to certain features of clinical interest and
importance. Yale M. J., 4: 275-291, 1897-8.
48. The significance of albumosuria in medical practice; sug-
gested by a fatal case of albumosuric myxedema treated
with thyroid extract. Am. J. M. Sc., n.s. 116: 30-42,
1898. Also: Tr. Assn. Am. Physicians, 13: 8-22, 1898.
49. Diabetes mellitus at the Massachusetts General Hospital
from 1874 to 1898. A study of the medical records.
With E. P. Joslin. J. A. M. A., 31 : 165-171, 1898. Also:
Am. Med.-Surg. Bull., 12: 861-868, 1898.
50. Aneurism of the arch of the aorta with radiograph. (Brief
case report). Boston M. & S. J., 139: 413) 1898.
51. Successful resection of the pylorus for cancer. (Brief case
report). Ibid., 139: 413, 1898.
52. The relation of idiopathic dilatation of the colon to phantom
tumor, and the appropriate treatment of suitable cases
of these affections by resection of the sigmoid flexure.
Am. J. M. Sc., 118: 1 25-137, 1899.
53. Multilocular cystoma of the pancreas. Tr. Assn. Am.
Physicians, 15: 254-261, 1900. Also: Am. J. M. Sc.,
120: 184-190, 1900.
54. Some surgical tendencies from a medical point of view.
Med. News, 79: 1009-1015, 1901. Also: Boston M. & S.
J., 145: 693-699, 1901.
55. Certain characteristics of osteitis deformans. Am. J. M.
Sc., n.s. 124: 814-825, 1902. Also: Tr. Assn. Am. Physi-
cians, 17: 398-405, 1902.
56. Typhoid fever at the Massachusetts General Hospital during
the past seventy-eight years. Mortality; intestinal hemor-
rhage; perforation; relapse. 14 pp., 8°, 1902.
57- Additions to Diseases of the liver, pancreas and suprarenal
capsules, by L. Oser, E. Neusser, H. Quincke, G. Hoppe-
Seyler, etc., Phila., Saunders, 1903.
58. Herpetiform and bullous dermatitis. (Case) Boston M. &
S. J., 148: 343-344, I9°3-
59. Chonro-dystrophic dwarf. (Case) Ibid., 148: 344-346,
1903.
Reginald Heber Fitz 4.53
0. The clinical significance of arteriosclerosis. Ibid., I4S:
357~359, I 9°3*
1. The pancreas and pancreatic diseases. The symptomatology
and diagnosis of diseases of the pancreas. Trans. Cong.
Am. Phys. & Surg., 6: 36-54, 1903. Also: Boston M. &
S. J., 148: 601-608, 1903. Also: Am. Med., Phila., 5:
907-912, 1903.
2. Some observations on appendicitis. Boston M. &: S. J.,
1 5 1: 339 - 34 T , x 9 0 5’
3. A brief consideration of some of the results of the surgical
treatment of cancer of the stomach. Ibid., 152: 65-66,
J 9°5-
4. Intrapleural lipoma; acute pericarditis; pericardial explora-
tion. Am. J. M. Sc., n.s. 130: 7S5-789, 1905.
5. The borderland of medicine and surgery. Boston M. & S.
J., 156: 655-662, 1907.
6. The early diagnosis of gall stones. Yale M. J., 15: 209-222,
1908-9.
7. Zabdiel Boylston, inoculator and the epidemic of smallpox
in Boston in 1721. Johns Hopkins Hosp. Bull., 22:
3 1 573-7> I 9 11 *
iS. The diagnosis of abdominal disease. An address before the
Springfield Academy of Medicine, Springfield, Mass.,
Nov. 14, 1911. Printed by request.
19. The introduction of inoculation. (Letter) Boston M. &
S. J., 166:356-357, 1912.
0. Continuous versus interrupted hospital service. Ibid., 166:
399-400, 1912.
1. Memorial to Maurice Howe Richardson, M.D. Ibid., 167:
903-907, 1912.
BIBLIOGRAPHY OF BIOGRAPHIES
lo R. H, Fitz, in honor of his 65th birthday, May 5, 1908.
Boston M. & S. J., 158: 605-748, 1908.
biography by A. K. Stone. Bull. Harvard M. Alumni Assn.,
n.s. 6: 71-75, 190S. Also: Pub. Mass. Gen. Hosp., 2:
350 - 354 , i 9 oS -
454 Medical Classics
Memorial addresses by W. W. Keen and C. W. Eliot. Meeting
Held at the Harvard Medical School, Boston, Mass., Nov.
17, 1913. Jamaica Plain, Jamaica Pr. Co., 45 pp., 8°, 1913.
Biography by F. C. Shattuck. Harvard Grad. Mag., 22, 1913.
Dr. Fitz’s services to surgery. By W. W. Keen. Boston M. &
S. J., 169: 893-895, 1913.
Dr. Fitz’s contribution to pathology. By W. T. Councilman.
Ibid., 169: 895-897, 1913.
Dr. Fitz as a teacher. By W. S. Thayer. Ibid., 169: 897-898,
I 9 I 3-
Dr. Fitz’s association with the Massachusetts General Hospital.
By H. P. Walcott. Ibid., 169: 899-901, 1913.
Dr. Fitz’s service to medical education. By C. W. Eliot. Ibid.,
169: 901-903, 1913.
Obituary. J. A. M. A., 161: 1390, 1913.
Obituary. Med. Rec., N. Y., 84: 626, 1913.
Obituary. Johns Hopkins Hosp. Bull., 25: 87-89, 1914.
Biography by H. A. Kelly. Boston M. & S. J., 180: 75-78, 1919.
Biography. Medical Life, 29: 323, 1922.
Biography. Med. Rev. of Rev., 34, 1928.
Biographical sketch and abstract of article of 1886 on appendicitis.
In: Classic Descriptions of Disease by R. H. Major. Spring-
field, 111., Thomas, 1932, pp. 620-622.
Biographic note by Reginald Fitz. Harvard Med. Alumni Bull.,
7: 4 2 ~45> 1933-
INDEX TO BIBLIOGRAPHY
Reference Year
Abdominal disease 68 1911
Albumosuria 4 g 1898
Amoebic dysentery 33 1891
Amyloid 21 1886
Aneurism of aorta 50 1898
Appendix vermiformis 22 1886
24 1888
27 1890
29 1891
34 1891
62 1905
Reginald Heber Fitz 455
Reference Year
Arteriosclerosis 60 1903
Belladonna 1 1868
Bigelow, Henry Jacob 30 1890
Boylston, Zabdiel 67 1911
Cholera . 20 1885
Choroid, sarcoma of 6 1872
Colon, dilatation of 52 1899
Dermatitis 5 8 1 9°3
Diabetes 47 1897
49 1898
Diabetic coma 16 1881
Dwarf 59 1903
Embolism 12 1 877
Esophagus, diseases of 14 1896
Esophagus, rupture of 11 1 877
Fasciola Jacksoni 10 1876
Gallstones 66 1908
Gastric ulcer 31 1890
Harvard Medical School 36 1892
Hemorrhage, intraperitoneal 41 1893
Hydrophobia 14 1878
17 1881
Inoculation 69 1912
Intestinal obstruction 25 1888
Liver, diseases of 18 1881
Monstrosity 4 1871
Omphalo-mesenteric remains 19 1884
Osteitis deformans 55 I 9 02
Pancreas, cystoma 53 I 9°°
Pancreatitis 26 1889
2.8 1890
38 1893
61 1903
7 187 3
39 i8 9 2
Pathology
Medical Classics
4 5 6
Reference Tear
Pelvic inflammation 35 1892
Pericarditis 64 1905
Pneumonia 46 *897
Pregnancy (ectopic) 9 1 875
Pylors, cancer of 51 j S9S
Richardson, Maurice Howe 71 1912
Stomach, cancer of 63 J905
Tuberculosis 4 1 gy I
Typhoid fever 23 iggg
1891
TllJ ^$ACTlt)Ss
"> in,
J "it:- rv< . ..
M,r, ,
’S8 G .
Perforating Inflammation of the
Vermiform Appendix; with
Special Reference to its Early
Diagnosis and Treatment
REGINALD H. FITZ, M.D.
Shattuck Professor of Pathological Anatomy in Harvard University
Published in Transactions of the Association of American Physicians, I: ioj-136, 1SS6
B Tg^gT APPEARS that even the most recent sys-
Vm.SA terna ^ c wr * ters are by no means agreed as to
yyJfzQ the exact relation of inflammation of the cecum
and that of the appendix to peritonitis and
perityphilitis. The vital importance of the
timely and appropriate treatment of the disease
in question is becoming more and more apparent. Such treat-
ment is often postponed till hopeless, even if its application is
at any time entertained. It was, therefore, to be anticipated
that the critical consideration of a large number of unquestionable
cases of perforation of the cecal appendix might serve to make
prominent the features essential for diagnosis and treatment.
In 1S34, James Copland, in his Dictionary of Practical Med-
ian ef first discriminated between inflammations of the caecum,
the vermiform appendix, and the pericaecal tissue. Isolated
cases of fatal inflammation of the appendix had been published
from time to time before this date. Their importance did not
1 Vol. i. p. C77.
459
460 Medical Classics
become well recognized, however, till after Dupuytren s views
had been made known concerning the relation of the caecum to
the production of what had hitherto been termed iliac abscess,
or phlegmon of the iliac fossa. At the instigation of this eminent
surgeon, Husson and Dance 1 published an article on the subject,
apparently expressing his ideas. These were subsequently
personally presented by him in his Lectures on Clinical Surgery .*
In consequence of the interest thus aroused, Goldbeck, 5 at
the suggestion (p. 108) of Puchelt, of Heidelberg, wrote his
graduation-thesis upon the same subject. He adopted the views
of the French writers, and applied the term peri typhili tt s to the
disease described. His essay contains the report of a case of
perforation of the appendix and associated peritonitis. But he
regards it as one of fecal retention, and as quite distinct from the
perityphilitis or inflammation of the connective tissue around
the caecum. He states that in fatal cases of the latter affection
the appendix has been found intact.
Of the various names connected with the early history of the
disease under consideration that of John Burne, Physician to
the Westminster Hospital, deserves particular mention. In the
first 4 of two admirable articles separated by an interval of two
years, he calls attention to the material difference in the character
of inflammation of the appendix and that of the caecum. He
attributes this difference to the peculiar conformation and situa-
tion of the former. His second paper 5 contains an additional
number of cases of affections of the caecum and appendix, a
criticism of the opinions of the French writers, and a reiteration
of his own views with such modifications as a more extended
experience permitted. The name typhlo-enteritis is offered as
an equivalent for inflammation and perforative ulceration of
the caecum and of the appendix.
In the interval between the publication of the above-mentioned
articles, Albers 6 contributed a paper on inflammation of the
1 Repertoire Gen. d’Anat., etc., 4: 154, 1827.
5 Lemons Orales de Clin. Chir., 3: 330, 1833.
* Uebereigenth. entz. Geschw. i. d. rechten Huftbeingcgend, 1830.
4 Med.-Chir. Trans., ao: 219, 1837.
s Ibid., as: 33, 1839.
Inflammation of Appendix 461
caecum. He first introduces the term typhilitis and perity-
phlitis. He charges Puchelt and foreign writers with confounding
the last affection with the acute and stercoral varieties of tv-
philitis. . The frequent termination of the perityphilitis in abscess
is recognized, likewise the possibility of communication between
the pus-cavity and that of the appendix or caecum. This
communication he regards as secondary. He says, 1 * “It is not
at all clear just why the processus vermiformis should be so often
affected, for in this disease perforation of the caecum should
be far more likely than that of the appendix.”
Although the term perityphlitis thus became synonymous
with inflammation of the pericaecal tissue, the tendency was
inevitably (p. 109) toward the recognition of a somewhat similar
clinical picture and a different anatomical seat. Oppolzer 5 dis-
criminated between cases of perityphlitis where the inflammation
was situated in the connective tissue about the caecum, and
others where the inflammatory swelling lay between the iliac
fascia and the bone. These were further distinguished from
cases of encysted peritonitis in this region, and from perforation
of the appendix. The latter was stated to be always productive
of a circumscribed peritonitis, except when the perforation took
place through the adherent peritoneum. Then both peritonitis
and inflammation of the subperitoneal tissue would occur. The
anatomical seat of the inflammatory process was thus further
complicated. Oppolzer suggested the term paratyphlitis, which,
according to Eichhorst, 3 4 represents an inflammation of the
connective tissue behind the caecum, while perityphlitis desig-
nates an inflammation of the peritoneal coat of the caecum and
appendix. Typhlitis is applied to an inflammation of the ap-
pendix and of the caecum. Whittaker* uses the same definitions,
while Ziegler 5 applies the term typhlitis to inflammation of the
vermiform appendix, and perityphlitis to that of the parts in
its vicinity.
1 Op. at., p. 19.
1 AUg. Wiener med. Zeitung, "0: Si; cis £6, 1S5.'.
1 Handb. d. Spec. Path. undTherap., iSe, iSS,.
4 Pepper’s System of Pract. Med., Si 4 > tSS(.
5 Lehrb. d. Path. Anat, 4te AuS., as 1, JSS:.
^62 Medical Classics
The clinician obviously recognizes as of the chiefest importance
the parts to which local treatment may be directly applied.
His attention is thus conspicuously directed to the caecum,
which may be evacuated, or to the perityphlitic abscess, which
may be emptied. The pathologist looks for the seat and causes
of the disease, and finds that in most fatal cases of typhlitis
the caecum is intact, while the appendix is ulcerated and perfo-
rated. He sees that the so-called perityphlitic abscess exists
in the pericaecal fibrous tissue; it is in most instances caused by
an inflamed appendix. Finally, if the encysted peritoneal ab-
scess, or the abscess in fibrous tissue behind the caecum, does
communicate with the latter, such an opening is usually the
result, not the cause, of this abscess.
With , 1 influenced by the predominant importance of the in-
dependent consideration of inflammation of the appendix and
its results, uses the term appendicular peritonitis to indicate the
perityphilitis proceeding (p. no) from disease of the appendix.
As a circumscribed peritonitis is simple one event, although
usually the most important, in the history of inflammation of the
appendix, it seems preferable to use the term appendicitis to
express the primary condition. This may terminate as an appen-
dicular peritonitis or as a paratyphlitis. In like manner the
rare, primary, perforating typhlitis (caecal perforation) may be
followed by a perityphlitis— that is, an encysted peritonitis about
the caecum, or by a paratyphlitis. The perityphlitic abscess
of the surgeon, when seen early, is thus usually an encysted
peritonitis of appendicular origin. More rarely, at this date,
it may be the result of a suppurative paratyphlitis. The causes
of this last affection are numerous and by no means confined
to the appendix or caecum, although a perforating inflammation
of each of these parts of the intestinal tract may act as a cause.
Any attempt at explaining the various results of an inflam-
mation of the appendix must necessarily be preceded by a state-
ment of the peculiarities it may present with respect to structure
and position. These peculiarities, though in part of congenital
origin, in most instances bear evidence of having been acquired
Nordiskt Med. Ark., vii. i, London Med. Record, 8: 213, 1880.
Inflammation of Appendix 463
as the result of previous disease. This statement, based upon
a long personal experience, is more than confirmed by the obser-
vations made elsewhere. Matterstock 1 states that Tun cel,
during a period of two years at the Hamburg Hospital, found
30 instances of partial or complete obliteration of the appendix,
43 cases of catarrh and fecal concretions, ia of abnormal ad-
hesions, and 11 of tuberculous ulcers. All these in addition to
perforations, and despite the fact that attention was not in-
variably directed to such peculiarities. Toft, as referred to by
With, 2 found the appendix diseased in i io out of 300 post-mortem
examinations, every third person thus possessing a diseased
appendix.
Personal observations have enabled me to recognize consider-
able variations in the length of the appendix, the longest being
nearly six inches. Wister 3 * alludes to one which was nine inches
long. It is frequently seen with an attached fold of peritoneum
and fat tissue, suggesting an omentum or mesentery. Its free
end has been found in the iliac fossa, as well as behind the caecum;
along the brim of the pelvis and hanging into the cavity of the
latter. Irregular positions (p. ill) have often been associated
with fibrous adhesions. The appendix has been found thus
attached not only in the places above mentioned, but also with
its tip directed upw r ard and its course more or less parallel with
that of the caecum, either behind, to the right, or to the left of
this structure. It has also been found adherent to the mesentery
with its tip bent at right angles and lying between the appendix
and this structure. Kraussold* observed its course directed
upward and backward, forming a loop around the ileum with
its tip directed forward. It has been seen pointing outward,
then forward, forming a loop around the lower end of the caecum
with its tip behind the latter.
Firket 5 records the adherence of the appendix to the ileum
throughout the length of the former, with a communication
1 Gcrhardt’s Handb. d. Kinderkrankh., 4: $9",
’ Loc. cit.
’Trans. Co]]. Phys. Philada., n.s. j: 14", lS 56-6—
* Volkmann’s Samml. klin. Vortr., 191: 1 5 1
* Ann. d. 1 . Soc. M6d.-Chir. d. Liege, ci: iSS-
464 Medical Classics
between the cavities of the two and without an evident ulceration
of the mucous membrane. Adherence to the rectum with a
communication between the cavities of each is recorded . 1 Ad-
hesions of the tip to the mesentery, the rectum, and bladder
are frequent. Its presence in a hernial canal led Shaw 2 to suspect
a disease of the testicle. Thurmann 3 records a like occurrence,
and the formation of a scrotal tumor as large as the two fists
in consequence of an inflammation of the appendix. Its tip
has been found 4 adherent to the abdominal wall in the vicinity
of the navel, and pus has been discharged from it at this point.
Complete or partial obliterations of the canal are frequent.
In the former instance a solid cord results. In the latter, a con-
siderable cystic dilation of the tip may follow; or a funnel-shaped
pouch at the origin is often associated with obliteration of the
remaining portion of the tube.
These variations in length, position, and patency, whether
congenital or acquired, are of obvious importance in explaining
many of the apparent differences in the clinical histories of
typhlitis and perityphlitis. Their significance in the etiology
of appendicitis will appear directly.
The presence of foreign bodies in the canal of the appendix
is of frequent occurrence. These are a variety of seeds, especially
of fruit. Less common are hairs, particularly bristles, worms
of their eggs, shot, pins, lipls, and gall-stones. By far the most
numerous are (p. 112) moulded masses of inspissated feces, more
or less cylindrical in shape and of extreme variation in density.
Some are of the consistency of normal excrement, while others
are of stony hardness in consequence of their infiltration with
earthy salts. The relative frequency of their presence in the
appendix is manifested by the records of fatal cases of appendi-
citis, but their actual frequency far exceeds the number of these
cases. . In my own experience, it is rather the rule than the
exception for the appendix to contain moulded, more or less
inspissated feces.
1 Trans. Lond. Path. Soc., 27: 161, 1876.
2 Ibid., i: 270, 1848.
3 Prov. Med. and Surg. Journ., 477, 1848.
* Lancet, 2-. 565, 1839-40.
Inflammation of Appendix 46 5
Xhe frequency of such retention may be due to the congenital
or acquired peculiarities of the appendix already described.
German writers attach a certain importance to the presence of
a valve-like projection of mucous membrane, discovered by
Gerlach, 1 * at the mouth of the appendix. Although a pinhole
opening may result, any considerable obstruction must be of
extreme rarity. The habits of individuals with reference to
diet and regulation of the bowels are of unquestioned importance.
Equally significant is the controlling fact that most persons
suffering from habitual constipation and accustomed to swallow
the seeds of fruit, escape inflammation of the appendix.
Recognizing the lack of agreement in the use of the term
typhlitis and perityphlitis, a collection has been made of 257
cases of perforating inflammation of the appendix. By limiting
the attention to the essential features of these cases, it was
thought possible to recognize the characteristics of this sharply
defined affection, by means of which it might be differentiated
from all others occurring in this region. At the same time
a comparison is drawn between many of these characteristics
and those occurring in cases of typhlitis and perityphlitis. The
latter terms are sufficiently indicative of a clinical picture, al-
though its seats and causes suggest the importance of shades
of distinction; 209 of these cases have been collected, and serve
as the basis of a series of tables to be contrasted with those
obtained from the analysis of the 257 cases of appendicitis.
The etiological importance of the presence of fecal masses and
of foreign bodies in the production of inflammation of the ap-
pendix is well recognized. Matterstock : found in 169 cases of
fatal perforating appendicitis, that fecal concretions were present
in 53 per cent, and foreign bodies in 12 per cent. In the scries
here collected, out of 152 (p. 113) cascs ^ 1C percentage 3 of fecal
masses was 47 per cent, that of foreign bodies 12 per cent. It
thus appears that in nearly one-half of the cascs more or less
inspissated feces were found, and that in nearly onc-cighth of
the series fo reign bodies other than feces were present. linir.,
1 Zdtschr. f. rat med., 6: \ 1 , 1S4".
: Op. at. __ .. , ,
1 In general whenever percentages are given, tract:"! c <..*ter.. ..t -
^66 Medical Classics
in about three-fifths of all cases of perforating inflammation of
the appendix either dried feces or foreign bodies were present
in the tube. When seeds are stated to have been found, the
evidence is not always sufficient to exclude the possibility of a
mistake having been made as to the nature of the foreign body.
Notwithstanding this large percentage, the reality is undoubtedly
much greater. Many are overlooked at the time of making the
examination, others are macerated in the contents of the abscess.
Still others, perhaps, escape with the pus, which makes its way
outward through the various channels by which the abscess may
communicate with the surface of the body.
The frequent immunity of the appendix from inflammation
in the presence of inspissated feces and foreign bodies suggests
the importance of other factors in the etiology. External vio-
lence is occasionally recorded as an immediate precursor of
the attack. Among the 257 cases were 19 who were supposed
to have received an injury, the result rather of indirect than of
direct violence; from lifting a heavy weight in 9 instances, and
from a fall or blow in 10. Among 209 cases of typhlitis and
perityphlitis external violence immediately preceded the attack
of the disease in 10 per cent.
Disgestive disturbances are of obvious importance in the
etiology of inflammation of the appendix, since this organ is
a part of the alimentary canal. There were 15 instances of
prolonged constipation, 9 of diarrhoea, and 6 of vomiting. The
attacks of diarrhoea and vomiting -were usually the result of
indiscretion in diet, but they were sometimes occasioned by the
use of domestic remedies. These were administered for the
relief of constipation or other disturbances attributed to a sluggish
action of the stomach and bowels.
Among the cases of typhlitis and perityphlitis were 38 of
constipation, 15 of diarrhoea, and 3 of vomiting; these symptoms
being of apparent etiological importance.
Notwithstanding the frequency of typhoid fever and of in-
testinal tuberculosis, in which affections the mucous membrane
of the appendix is often diseased, a resulting perforation seems
to have been relatively (p. n 4 ) infrequent. There were 8 of
Inflammation of Appendix 467
a perforating ulcer of the tuberculous appendix, and 3 of this
lesion in convalescence from typhoid fever.
Among the 209 cases of typhlitis and perityphlitis were 2
occurring in tuberculous persons.
The consideration of sex in 247 cases gives the following results:
197 males, 80 per cent, and 50 females, 20 per ccnL These
percentages are the same as those found by Fenwick 1 in the
analysis of 130 cases.
In 209 cases of typhlitis and perityphlitis there were 156 males,
and 53 females; 74 per cent of the former, and 26 per cent of
the latter.
The age in 228 cases of appendicitis is recorded as follows:
From 2 o months to io years zz « io per cent.
<(
10 years
‘*oo “
5 6 5=5
3s •
it
20 “
" 3 ° "
2 $ *
30 “
“40 “
34 “
IS *
40
M 50 “
8 **
3 '
it
5 ° “
“ 60 “
5
it
60 “
M 7° “
1 »
i 44
<1
70 "
"78 “
1 «
* “
The age of the youngest patient was 20 months, that of the
oldest, 78 years; 173 cases, 76 per cent of the entire list, were
under the age of 40 years, and nearly 50 per cent were under the
age of 20 years. Fenwick’s 5 table of ages is based upon the
consideration of 97 cases, and shows smaller percentages for
the several decades up to the age of 40 years.
The age of the patient in 17S cases of typhlitis and perity-
phlitis was:
From
10
20
3 o
40
5 °
60
years to io
“ “ 20
tt u
3 °
“ 40
tc ((
5 °
" " 60
a ( t
73
“ " 7S
years ™ " 6 P r cc —
“ S 3 "
" S 3 - 3 * “
“ s 5 - u “
« i? « io "
“ io ■* 6
” 4
** I
1 Lancet, a: 9S7; 1039, 1SS4.
1 Loc. cit.
468 Medical Classics
From the above consideration it is apparent that perforating
appendicitis is a disease most frequently occurring among healthy
youths (p. 1 15) and young adults, especially males. Further,
that attacks of indigestion and acts of violence, particularly
from lifting, jumping, and falling, are exciting causes in one-fifth
of the cases. A local cause is to be found in more than three-
fifths of all cases in the retention in the appendix of more or less
inspissated feces, or in the presence there of a foreign body.
The retention of feces may be promoted by a constipated habit,
but congenital or acquired irregularities in the position and
attachments of the appendix frequently act as favoring causes.
A fact in support of the last-mentioned statement is to be found
in the frequency of successive attacks, one or more, of inflamma-
tion of the appendix. Among 257 cases were 28, II per cent,
which presented similar symptoms of greater or less severity, at
various intervals before the final attack. Recurrence is men-
tioned in 23 out of 209 cases, again 11 per cent, of typhlitis and
perityphlitis.
The inflammatory process once excited, its course and results
show extreme variations. A simple catarrhal appendicitis is
to be recognized anatomically, but it is doubtful whether its
clinical appreciation is possible. This appendicitis, in the
absence of a concretion or foreign body, may progress toward
ulceration, even to a peritonitis, which may terminate fatally.
In the presence of a foreign body or concretion these events are
of likely occurrence. On the one hand, the inflammation may
result in the more or less complete obliteration of the canal of
the appendix, with or without circumscribed dilatation. On the
other, the ulcerative process becomes associated with a necrosis
of the wall, a peritonitis, usually circumscribed at the onset,
and. perforation. In those cases where the appendicular peri-
tonitis represents the extension of an inflammation through the
wall of the appendix without perforation, permanent adhesions
of the appendix to neighboring parts remain as evidence of the
process. When it is associated with necrosis of the wall, the
inflammation of the peritoneal coat tends to become diffused
and productive of serous and cellular exudations. The adherence
Inflammation of Appendix 469
of coils of intestine to each other and to the abdominal wall
favors the accumulation of the exudation in a limited space, and
thus the formation of the tumor. At this stage the anatomical
condition is a circumscribed peritonitis, the appendicular peri-
tonitis of With. In certain instances the term perityphlitis
might be applied in an exact anatomical sense, as the peritoneal
inflammation frequently extends to the serous investment of
(p. 1 1 6) the lower part of the caecum. But in the last two
cases of fatal appendicitis examined by me, the appendicular
peritonitis was wholly pelvic. The changes observed in the
appearance of the serous covering of the caecum were of the
same character as those affecting the peritoneum elsewhere.
This peritoneal abscess may then become absorbed, or its con-
tents may escape into the general peritoneal cavity through rup-
tured or softened adhesions. In the latter event, as a rule, death
rapidly follows. The exceptional case reported by Markoe 1 may
be regarded as one of extreme rarity. A child with symptoms
of general peritonitis on the second day, died a month later
from another disease. The appendix had been perforated and
the intestines were adherent in different places.
The product of the circumscribed peritonitis varies exceedingly
in quality and quantity. Although it is usually thin, discolored,
and very offensive, it may be thick, yellow and odorless. In
the postmortem examination of a case of recent occurrence,
where general peritonitis was the cause of death, the abscess
contained perhaps an ounce of pus. The peritonitis was the
result of a secondary mesenteric thrombophlebitis, where the
primary appendicular peritonitis was apparently in a retrograde
condition. The acute stage of the disease lasted more than
six weeks. Barrett 2 states that he removed from a perityphlitic
abscess, on the sixty-second day, more than a gallon of pus,
liquid feces, and scybala. The presence of the last element
indicates a communication with the large intestine.
If the case does not terminate as thus stated, the tumor may
suddently diminish in size with the discharge of pus from a
1 Am. Med. Monthly, 8: 231, 1857.
5 Va, Med. Monthly, 2: 120, 1S75-76.
4^0 Medical Classics
hollow organ, as the intestine, bladder, or vagina. The anterior
abdominal wall may become perforated and a sinus be established
opening in the groin, lumbar region, or at the umbilicus. Shaw 1
mentions the occurrence of multiple abscesses of the scrotum
from a perforated hernial appendix, and Thurmann 2 records
a similar instance. Such sinuses often remain open for a long
time, even many years. Through the kindness of Dr. A. T.
Cabot, of Boston, I saw a patient with a fecal fistula which had
existed for nineteen months. At the outset a tender swelling
in the right groin had been incised, but the wound never (p. 117)
healed. After an operation to promote the healing of the sinus,
about an inch of the perforated appendix protruded from the
wound. A similar protrusion had taken place six months earlier.
The outer surface of the appendix was smooth, of a dusky red
color, and the margin of the opening was sharply defined. Pres-
sure upon the abdominal wall over the caecum, caused soft,
yellow, intestinal contents to appear in the wound.
The abscess may contain sloughs of tissue and yet be intra-
peritoneal. In a recent post-mortem examination I removed
from the encysted abscess around the appendix, a slough, three
inches in length representing the detached peripheral portion
of the tube. Ballou 3 records a case where the sloughed appendix
was discharged per anum, the patient recovering. In the case
reported by Pooley, 4 apparently the entire appendix escaped as
a slough from the wound.
The more protracted the course of the disease the greater is
the probability of the destruction of the peritoneum forming
the^ wall of the abscess. With the perforation of the parietal
peritoneum may occur extensive necrosis, purulent and fecal
infiltration of the abdominal walls. Within three weeks the
iliac muscle may be destroyed and the ilium be bared. The
course of the psoas and iliacus may be followed into the thigh,
and extensive and deep-seated destruction of tissue with fecal
1 Loc. dt.
2 Loc. dt.
1 Trans, R. I. Med. Soc., 2: 418, 1877-82.
4 N. Y. Med. Record, 10: 267, 1875.
Inflammation of Appendix 471
infiltration be present in this region. The pus may extend
through the obturator foramen, forming a deep-seated abscess of
the hip and thigh, and may enter the hip-joint.
Moore 1 has shown that disease of the hip-joint may follow
perityphlitis, and Gibney 2 has called attention to the possibility
of mistaking cases of perityphlitis for disease of the hip-joint.
The primary appendicular peritonitis may in like manner be con-
tinued into the tissues behind the caecum, and thus a secondary
paratyphlitis or perityphlitic abscess be occasioned. So various
are these possibilities that every case of so-called perityphlitic
abscess must be regarded as primarily one of a perforating ap-
pendicitis unless proven to be the contrary.
With the frequent eventual destruction of the peritoneal wall
of the abscess is the possibility of death from hemorrhage.
Conant 3 describes the case of a young man who died at the end
of three weeks. There (p. 118) was no general peritonitis, but
the abscess communicated with the caecum (the appendix being
destroyed) and held a pint of clotted blood. Fatal hemorrhage
from ulceration of the deep circumflex iliac artery is recorded
by Bryant. 4 This case is not unlikely to have been one of ap-
pendicitis, although the condition of the appendix is not stated.
Again, Powell 5 reports a case where the appendix was adherent
to the internal iliac artery, the cavities of the two being in com-
munication. The colon and caecum were distended with gas
and dark blood.
The occurrence of disease of remote parts may be alluded to,
as abscesses of the liver from pylephlebitis or portal embolism
in consequence of a mesenteric thrombophlebitis near the ap-
pendix. The affection of the liver and portal vein may be the
result of a direct continuance of the phlebitis, or may follow
putrid embolism from a thrombus in the immediate vicinity
of the appendix. The extension of a secondary paratyphlitis
1 Lancet, 2 : 514, 1864.
2 Am. Joum. Med. Sri., 81, 1881.
3 Am. Med. Monthly, 1858, x. 359. •
4 British Med. Joum., 2 : 43, 1884.
5 N. O. Med. and Surg. Joum., 11: 468, 1855.
472 Medical Classics
may cause perforation of the diaphragm with a consecutive
pleurisy or pericarditis.
In considering the symptoms of appendicitis } it is to be noted
that attacks of inflammation frequently occur without giving
rise to any characteristic symptoms, and often without a sugges-
tion of any distinct malady.
A comparison of the results' of post-mortem examinations wflth
the records of the previous histories of patients justifies this
statement, unless it be urged that the disease occurred so early
in life as to have been unappreciated or forgotten. Out of
IT] cases of perforated appendix, however, 22, about 10 per cent,
were under the age of ten years. This number is far too small
to account for the occurrence of evidences of disease of the
appendix in more than one out of every three autopsies.
The records of the Massachusetts General Hospital state that
an individual with an appendix a half inch long, thickened,
curved, and intimately adherent to the thickened and opaque
subjacent peritoneum, never had symptoms of inflammation in
this region. Another patient was never sick before his fatal
illness, although the appendix and caecum were closely united
to the neighboring parts by old fibrous adhesions, and the canal
of the appendix was obliterated. Still another patient was
always well and strong till within eleven days of (p. 119) his
death, yet the appendix was converted into a solid fibrous band
intimately united by firm adhesions to the posterior wall of the
caecum. The severity, of these lesions suggests the probability
that apparently slight disturbances of digestion were overlooked.
The diarrhoea, constipation, or abdominal pain, especially when
occasionally recurrent, were regarded as characteristic of a feeble
digestion. There can be little doubt that a diagnosis of bilious
attack, colic, gastritis, enteritis, gravel, ovaritis, congestion of
the womb and the like, may not infrequently conceal the existence
of an inflamed appendix.
The latency of the symptoms in certain cases of appendicitis
is such that the eventual diagnosis is obscured, and the desirable
method of treatment hopelessly postponed. Buck 1 reports that
a sailor was at work rolling barrels of flour till the day of his
1 New York Medical Journal, 2: 40, 1866*
Inflammation of Appendix 473
admission to the hospital. He then had a prominent iliac tumor
extending along the outer half of Poupart’s ligament. Fluctua-
tion was transmitted from it to below the inner half of the liga-
ment. Another sailor left Portland for New York, April 12,
1886, and arrived five days later. In the meantime he purged
himself in consequence of a right iliac pain. Although suffering,
he kept at work during the following week. He then left for
Boston, where he arrived on the thirteenth day after the be-
ginning of the pain. Symptoms of general peritonitis were
evident, and he died the next day. General peritonitis was
present, the result of an encysted inflammation about the appen-
dix. This organ formed a gangrenous slough lying in the cavity
of the abscess.
The latency, as well as the frequent obscurity, of the symptoms
of appendicular inflammation is thus apparent. The presence,
therefore, of the symptoms now to be mentioned, in individuals
from whom the history of one, and particularly of several such
attacks is to be obtained, is of marked importance in aiding
diagnosis.
Sudden, severe abdominal pain is the most constant, first,
decided symptom of perforating inflammation of the appendix.
It occurred in 216 out of 257 cases, 84 per cent. In most in-
stances it is present in apparently healthy individuals, in a few it
follows an attack of diarrhoea.
The pain is usually intense, rarely slight, and is occasionally
accompanied by a chill, or nausea and vomiting (p. 120). The
following tables shows its localization in 213 cases of appendicitis,
and, by way of contrast, in 92 cases of typhlitis and perityphlitis:
Appendicitis Typhlitis & Perityphlitis
Cases Per Cent. Cases Per Cent.
In right iliac fossa 103 = 48 55 — 60
abdomen 7 6 = 36 31 = 34
“ hypogastrium II = 5 o
umbilical region 9 = 4 2 = 2
epigastrium 4=2 4 = 4
stomach 3 = 1 o
hepatic region 3 = 1 o
“ left iliac fossa 3 = 1 o
right hip and groin I = J o
Total 213 92
474 Medical Classics
It is quite probable that the number of cases of more exactly
localized pain would have been considerably greater had attention
been specially directed to this point. Many of the recorded
cases of abdominal and hypogastric pain would undoubtedly
have permitted a more definite localization, especially as firm
pressure often discloses a sensitive spot at some distance from
the referred seat. Though usually limited to the fossa, the
pain sometimes extends upward as far as the liver, or downward
to the rectum, testicle, perineum, or thigh. The attack is oc-
casionally associated with great nervous anxiety, and is at times
followed by marked prostration from which the patient rallies
in the course of a few hours.
This sudden intense pain is presumably due, not to the actual
beginning of the disease, but to the separation of the fresh ad-
hesions of an acute appendicular peritonitis, and often, perhaps
usually, to the perforation of the inflamed appendix. It generally
represents the beginning of a more extensive peritonitis. An
attempt has been made to ascertain the date of occurrence of
this most important symptom. This was possible in 61 cases
of appendicitis, and in 64 cases of typhlitis and perityphlitis.
It occurred as follows:
Appendicitis
Cases Per Cent.
Typhlitis & Perityphlitis
Cases Per Cent.
On the 1st day in
41 = 67
*0
u
CO
't
“ “ 2nd “ "
5 = 8
10 = 16
" “ 3rd " "
2=3
" " 4 th « <f
4 ** 6
" " 5th “ «
0
Total
64
(p. 1 21)
If the pain is not accompanied by nausea and vomiting, these
symptoms are not unlikely to follow. Their occurrence is re-
corded in 15 cases of appendicitis, and in 44 out of 209 cases of
typhlitis and perityphlitis. The vomit quickly becomes green
in color, but in general this symptom is not distressing at this
stage of the disease. Diarrhoea is rarely present, while constipa-
tion is the rule.
Inflammation of Appendix 4.75
The abdominal pain is followed by fever as the next constant
symptom. The date of its appearance is noted in but 38 cases
of appendicitis, and in only 16 of typhlitis and perityphlitis.
It was present
Appendicitis
Typhlitis &
Perityphlitis
On the first day in
6 cases
“ “ 2nd " “
18 “
7 ••
“ " 3rd " “
9 “
0 “
“ “ 4 th “ “
6 "
"
'
38 cases
16 cases
The tempterature is rarely very high, and the constitutional
disturbances usually associated with an elevated temperature
are frequently slight, if not absent. The maximum recorded
in the cases here collected is 103. 5°F., but the range is usually
between ioo°F. and io2°F. With 1 noticed an elevation of nearly
io6°F. If violent or extreme changes take place, a complication
may be expected, as an abscess of the liver, or a pleurisy from an
extension of the local inflammatory process.
During the first three days following the onset of the pain,
micturition is occasionally disturbed. Perhaps unusually fre-
quent on the first day, it is likely to be difficult on or after the
third day. In certain instances the use of the catheter is re-
quired. A satisfactory explanation of this latter feature is to
be found in the abundant use of opium usually necessary at
this stage of the disease. The right testicle may be retracted
and swollen, in which case the course of the pain is apt to be
toward this gland.
The circumscribed swelling in the right iliac fossa now demands
consideration. This symptom, when present, is evidently of the
upmost value in diagnosis, as its appropriate treatment most
favorably modifies the prognosis. The swelling represents the
accumulation of (p. 122) the increasing exudation, at the outset
the product of the peritonitis, and lies beneath the adherent coils
of intestine which later become attached to the abdominal walls.
1 Loc. cit.
47 6 Medical Classics
Its usual seat is in the right iliac fossa, below a line extending
from the anterior superior spine of the ilium to the navel, nearer
the former and two finger-breadths above Poupart’s ligament.
It may lie nearer the median line or may approximate the iliac
crest. The swelling may be found in the pelvis in those cases
where the appendix becomes attached to the peritoneum of the
pelvic wall. It is rare for the primary swelling to be paracaecal,
although this variety occurs where the appendix lies embedded
behind the caecum.
The early products of the peritonitis are largely cellular and
fibrinous; scanty, opaque, greenish masses are found encap-
sulated. This condition is obviously not to be recognized by
physical signs. As the liquid exudation increases, dulness be-
comes apparent. This sign may be obscured by intervening
and adherent coils of intestine, especially if they are distended
with gas, when a superficial gurgling may be recognized. Again,
the contents of the abscess may be partly gaseous, a condition
more likely to occur later in the course of the disease. A cir-
cumscribed resistance is felt on palpation. As the part is often
extremely sensitive to pressure and the abdominal muscles tense,
the administration of ether or chloroform may be necessary to
confirm the diagnosis. A rectal examination not infrequently
permits the recognition of the tumor which abdominal palpation
fails to disclose, and should always be made in the latter event.
Owing to the position of the abscess beneath the transversalis
fascia, and to the fact that it is often covered by adherent coils
of intentine, a sense of fluctuation is rarely perceived till much
later in the history of the case.
The clinical characteristics of the tumor and its composition
are thus made evident by modified resonance on percussion,
circumscribed resistance on palpation, and a sense of fluctuation.
Notwithstanding the importance of these signs, the records of
257 . cases of appendicitis give comparatively little infor-
mation with reference to the date of their appearance. The 209
cases of typhlitis and perityphlitis give a more satisfactory
result.
Inflammation of Appendix 477
(p. 123) Dulness was first noticed on the
1st day in
Appendicitis
_ n
Typhlitis &
Perityphlitis
2 rnse<;
2nd 44 44
A
<(
O
a
^rd 44 44
I
«
7
a
4th 44 44
««
5
1
it
fth 44 44
I
u
a
6th 44 44
A
if
O
it
7 th 44 44
I
it
I
it
8th 44 44
I
€C
4
it
oth 44 44
O
it
I
U
10 th 44 44
O
it
2
tt
Total
12
cases
25 cases
Palpation showed the presence of the tumor on the
Typhlitis^
Appendicitis Perityphlitis
1st day in 1 case 4 cases
2nd 44 44 3 “ 6 44
3rd " 44 4 “ 8 44
4 th 44 44 2 44 8 44
5th 44 44 4 " 3 “
6th 44 44 5 44 6 44
7th 44 44 4 “ 4 “
8th 41 44 1 44 7 44
9th 41 44 o 44 11 44
30 th “ " O “ II 44
Total 24 cases 68 cases
An attempt has been made to determine the date at which
fluctuation becomes evident. As a rule, its appearance is so
late in the course of the disease (after the second week) as to be
of little diagnostic value. An exploratory puncture with the
needle of the aspirator is frequently recommended to determine
the nature of the tumor. Too much stress is not to be laid upon
this method of examination. If the aspirator fails to show the
presence of pus, even after repeated punctures in divers spots, it
by no means follows that pus is absent. Operators have fre-
quently exposed the transversalis fascia over the tumor, and
have then punctured it in several places. Pus not appearing,
the wound has been dressed. In the course of a few hours an
^^8 Medical Classics
abundant discharge of fetid matter has made its appearance in
the dressings and at the bottom of the wound.
It is evident, from the consideration of the above table, that
the (p. 124) presence of the abscess may be expected as early
as the third day. It may be large enough to contain some three
pints of fluid on the fifth day. The following case reported by
Peckham 1 apparently justifies the above conclusions.
His patient was a man twenty-seven years of age, who had
suffered from abdominal pain and diarrhoea for twenty-four
hours. He was then seized with a severe pain in the right iliac
fossa, which was fuller than the left, tender, and dull. On the
following day the whole abdomen was tender, but there, was no
complaint of pain. The day after there were great tenderness,
dyspnoea, cold hands and feet. The next day, the fifth of the
disease, and the fourth from the occurrence of the right iliac
pain, the patient died. There was acute peritonitis. In the
lower part of the abdomen was a space bounded by the bladder,
iliac bones and small intestine, the latter pushed up and covered
by false membrane. In the cavity were nearly three pints of
fetid, purulent fluid.
The chief danger from the appendicular peritonitis is that it
becomes general. Many of the records mention the time of
occurrence, not only of the iliac pain, but also of the subsequent
general abdominal pain. The latter is to be regarded as suggestive
evidence of the beginning of a general peritonitis, as the former
calls immediate attention to the exact nature of the disease.
The date of its occurrence is recorded in about one-fourth of
the cases of appendicitis, most of which were fatal, while it is
noted^ in but about one-tenth of the cases of typhlitis and peri-
typhlitis, which were nearly all instances of recovery.
General abdominal pain was present on the
* . . TypMiiS* Sc
Appendicitis Perityphlitis
- cases o cases
11 “ 6 M
ax “ 8 «
1st day
and "
3rd « ,
4 th " .
1 Boston Med, and Surg. Joum., 106: 159, iSSa.
Inflammation of Appendix
5th day
6th 44
Appendicitis
r «
Typhlitis &
Perityphlitis
0 cases
1 44
7th 44
4 “
8th 41
4 "
0 44
oth 44
2 "
0 44
y
10th 44
0 «
0 44
* o
72 cases
19 cases
(p. 125) In one of the cases in which this symptom appeared
on the first day death occurred on the fourth day. It was
stated that there was no perforation of the appendix, although
this structure presented a deep purple color and contained a
fecal concretion. General peritonitis was present and a con-
siderable quantity of pus was found in the pelvis and vicinity
of the appendix. In the other case the general abdominal pain
came on three hours after moderate pain in the bowels. It
radiated from the right iliac region. In sixty-six hours the
patient was dead. The intestines were glued together by a
butter-like lymph, but there was no serous or seropurulent
exudation.
It was thought desirable to ascertain the date at which tym-
panitic distention of the abdomen appeared. At the same time
it is recognized that this sign of a general peritonitis is of con-
siderably less value than that already stated.
Tympanites was present on the
Typhlitis/*
Appendicitis Perityphlitis
1 st day,
2nd 44 ,
3 ^ " ,
4 th 44 ,
5 th 44 .
6 th 44 ,
1 case
5 cases
8 “
1 case
38 cases 19 cases
It is evident, from the above tables, that the majority of cases
of resulting general peritonitis begin on the second, third, and
fourth days after the inflammation of the appendix is established.
This is inferred from the date of the occurrence of the general
abdominal pain in sixty per cent of the cases of appendicitis,
480
Medical Classics
and from that of tympanites in nearly ninety per cent of these
cases. The source of this early peritonitis is to be found, in
most instances, in the escape into the peritoneal cavity of the
inflammatory product encysted near the appendix. Although
usually small in quantity at this early period, its quality is ex-
ceedingly acrid.
The speedy death of the patient almost invariably results
from the occurrence of the general peritonitis. In 176 cases
the day of death was as follows:
On the id day in 8 cases = 4 per cent.
44 3d 44 “10 44 * 11 44 "
“ 4 th 44 “ ii 44 =7 “ “
“ 5 th “ "10 “ = 11 " "
44 6th 44 41 16 44 « 9 44 44
44 7th 44 44 21 14 = 12 44 44
44 8th 44 44 21 44 = 12 44 44
44 9 th 44 44 10 44 « 6 44 44
44 10th 44 44 8 44 = 4 44 44
44 nth 44 44 6 44 =3 44 44
44 12th 44 44 4 44 =2 44 44
44 13th “ " 4 44 =2 4 4 44
44 14th 44 44 1 44
44 15th 44 44 3 44
41 17th 44 44 1 44
44 iSth 44 44 1 44
44 19th 44 44 1 44
44 20th 44 44 a “
(98 in the 1st week, 56 per cent-)
(54 in the 2d week, 31 per cent,)
(8 in the 3d week, 4 per cent.)
In the 4 th week 7 cases = 4 per cent.
44 44 5th 44 4 44 = o “ «
44 44 7th 44 4 44 = 1 “ "
44 44 8th 44 1 ** — § 44 44
In fatal cases sixty-eight per cent, more than two-thirds,
die during the first eight days, and two-thirds of these die between
the fourth and eighth days inclusive.
Errors m the diagnosis of appendicitis have been numerous,
chiefly because the cardinal symptoms of localized pain, general
heat, and circumscribed swelling have not been duly appreciated
m their, defined sequence. Again, the extreme rarity of acute
perforating inflammation of the caecum, as compared with that
Inflammation of Appendix 48 1
of the appendix, has not been made sufficiently conspicuous.
The acute form of perforating appendicitis has been confounded
with inflammation of the caecum or typhlitis in an exact sense,
intestinal obstruction from intussusception or strangulation, pel-
vic peritonitis (haematocele) of vesical, ovarian, tubal, or uterine
origin, psoitis, and renal or biliary colic. More rarely a movable
kidney or a foreign body in the bladder has been suspected.
The chronic appendicular peritonitis and the chronic para-
typhlitis resulting from a perforating appendix have been con-
founded with the results of caries of the spine and hip-joint,
suppurative nephritis, intestinal tuberculosis, and cancer of the
caecum. An appreciation of the (p. 127) previous history of
the patient, the seat and character of the pain, the period of
occurrence of the fever, and the date of the appearance of the
tumor are necessary for an eliminative diagnosis.
A primary perforating inflammation of the caecum is ex-
tremely rare even in chronic dysentery or in chronic tuberculosis.
In an extensive research into the literature of the subject but
three cases of acute primary perforation of the caecum have been
found: one from a fishbone, another from a pin, and the third
from strangulation of the bowel. Two cases of rupture of the
caecum are recorded. So rare is the affection in question that
the possibility of a primitive, perforating caecitis may be dis-
regarded. Bartholow’s 1 communication on this subject relates
rather to the secondary perforation of the caecum from without.
Stercoral caecitis, on the contrary, is exceedingly common,
and is, perhaps, the most important of all the conditions with
which the perforating appendicitis may be confounded. The
history of this affection usually makes evident a period of pro-
tracted constipation in a person not especially young, vigorous,
and apparently healthy, who may have had similar attacks.
The pain is trifling for a long time, and the sensitiveness slight.
Fever is absent, or of late occurrence. The tumor is present at
the beginning as a distinct nodular or doughy mass, elongated,
and in the lumbar region. It is unnecessary to say that from
a stercoral caecitis may arise a perforative appendicitis which
1 American Journal of the Medical Sciences, n.s. 52: 351, 1866.
A g 2 Medical Classics
i
may end in perforation. Many of the so-called cases of typhlitis
terminating in resolution, associated with fecal retention, and
persisting after the removal of the feces, are undoubtedly of
this nature. . _
Intestinal obstruction from intussusception or strangulation
is characterized by the frequent absence of a suggestive previous
history. The pain is not so localized or intense, and the fever
is not conspicuous at an early stage. The abdomen is distended
and tympanitic at the outset, and is, at the same time, unusually
sensitive. Borborygmus and perceptible movements of the
intestine are associated with or followed by fecal vomiting.
Obstinate constipation and the retention of flatus are noticeable.
The tumor is absent when the intestine is strangulated, and it
is elongated, sausage-like, usually following the course of the
colon when intussusception is present. Tenesmus and (p. 128)
the rectal discharge of bloody mucus are important signs of the
latter affection, though they may occur when the appendix
is inflamed.
As four-fifths of the cases of appendicitis occur in males, and
as pelvic peritonitis suggests a doubt as to its diagnosis almost
invariably in females, it is evident that the question of sex is of
eliminative value in certain cases. But the doubt may arise
in the case of the female. Barker 1 has reported two cases, the
one of haematocele, fatal in forty-eight hours, diagnosticated as
inflammation of the appendix. The second patient also died on
the second day; the autopsy showed an inflamed appendix and
pregnancy, although the patient was supposed to have had a
haematocele. Suppressed catamenia and the incipient symptoms
of appendicitis not infrequently coexist. Again, the occurrence
of symptoms of appendicitis within twenty-four hours after
delivery is occasional, and more rarely it represents a cause of
aborriom In general, the symptoms and progress of a pelvic
peritonitis of pelvic origin would not be likely to suggest an
inflamed appendix. The symptom which is of the greatest value
m determining the onset of an appendicitis after delivery, is to
be found in the rapid development of the tumor without an
1 New York Medical Record, 18: 663, 1S80.
Inflammation of Appendix 483
obvious cause. When the appendicular peritonitis is pelvic in
its localization, the previous history and the absence of evidence
of disease of the genital tract are to be relied upon to direct
attention to the appendix as the cause.
An inflammation of the psoas muscle may be the result of an
appendicitis. If due to other causes, and acute in character,
the digestive disturbance is lacking, and the pain and sensitive-
ness are less, the tumor is more vaguely defined and tympanitic
from its deep seat, while the motion of the leg is early impaired.
A primary, acute suppurative process is of doubtful occurrence.
A biliary colic is rarely likely to suggest an inflamed appendix.
The seat and nature of the pain, the absence of fever and peri-
tonitis during the first week, and the possible occurrence of
jaundice would tend to eliminate this affection.
In the passage of a renal calculus the seat and character of
the pain differ. Fever and the iliac pain are absent. There is
no iliac tumor, and the examination of the urine may indicate
the probable presence of a foreign body in the ureter.
(p. 129) In chronic cases of inflamed appendix the abscess is
evident, and its treatment apparent. It may be mistaken for a
psoas abscess of spinal origin. If the latter affection is present,
evidence of disease of the vertebrae is usually to be obtained.
In disease of the hip-joint the impaired mobility and localized
sensitiveness of this articulation will be found more extreme
than is apparent in the flexed and adducted thigh usually con-
nected with a chronic perityphlitic abscess.
The histories of the cases of intestinal tuberculosis, chronic
suppurative nephritis, and cancer of the caecum are sufficient
to eliminate these causes of iliac and lumbar tumors, when disease
of the appendix is under consideration.
Perforating inflammation of the appendix sometimes proves
fatal from shock. Death usually follows from the production
of a general peritonitis by the direct extension of an appendicular
peritonitis, or by the rupture of adhesions producing an inter-
vening, encysted, peritoneal abscess. A general peritonitis may
also occur by the intervention of a mesenteric thrombophlebitis
484 Medical Classics
and its continuance to the portal vein and liver, with or without
portal embolism. Among the 257 cases of perforating appen-
dicitis are 11 of pylephlebitis.
In the protracted cases death may result from exhaustion.
Shock proves fatal within the first two days, death from an
extended peritonitis within the first week, and from a secondary
general peritonitis, as a rule, during the first two weeks.
The termination in resolution of a perforating appendicitis
undoubtedly occurs, but our present sources of information give
no absolute evidence as to the relative proportion of this class
of cases to those ending fatally. The consideration of a large
number of cases of typhlitis and perityphlitis offers a suggestion
as to the possible frequency. Of 180 cases thus designated
there terminated
By resolution 58 = 32 per cent
Spontaneous evacuation 33 = 18
Operation 89 = 50
1S0
It will be generally admitted that the spontaneous evacuation
of a perit3 r phlitic abscess is an event to be anticipated and guarded
against. Apart from the consequent dangers which may result,
possible fatal complications v r hich may precede the time of its
expected occurrence (p. 130) are a sufficient warning. It is,
therefore, important to bear in mind that two-thirds of the
cases of typhlitis and perityphlitis above tabulated v r ere of
unquestioned abscess.
The termination by resolution of nearly one-third may seem
a sufficient warranty for recognizing this result as frequent
enough to be anticipated in all cases.
That this conclusion is not justified appears from the fact
that twelve of these, about one-fifth of the entire number, thus
terminated at the end of the second week. Operative inter-
ference is demanded before this time in two-thirds of all cases,
hence but one-fourth may be expected to undergo resolution.
An additional argument against the plan of waiting with the
hope of the occurrence of resolution, is to be found in the fre-
Inflammation of Appendix 485
quency of recurrent attacks. Recurrence is recorded to have
taken place in 28 out of 257 cases of appendicitis, and in 23 out
of 209 cases of typhlitis and perityphlitis; that is, in about 11
per cent of each. It is at least suggestive of the importance of
not waiting too long for resolution, that the number thus ter-
minating during the last two days of the second week is seven
per cent of those ending in resolution. This number mayinclude
a considerable part of the recurrent cases which operative inter-
ference would have prevented.
The possibility of a termination by resolution must be recog-
nized, and the earliest therapeutic efforts should have this result
in view; especially as these efforts also tend toward localizing
the peritonitis. But, as Pepper 1 states, “the unjustifiable delay
permitted in many cases of typhlitis, whilst hoping day after
day for the more definite detection of suppuration, is the direct
cause of many avoidable deaths.”
To keep the bowels quiet should be the first and last thought.
Absolute rest in bed, liquid diet in small quantities often re-
peated, and, above all, sufficient opium to neutralize pain. A
sufficiency may seem enormous. Petrequin 2 gave a grain of
opium every hour till the pain was relieved, with the result of
administering 107 grains in six days. Clark 3 gave a boy, fourteen
years old, 1350 drops of laudanum in one day.
A cathartic or a laxative may be demanded by the patient or
friends, and an enema be thought desirable as a diagnostic aid.
It is to be (p. 131) remembered that these may be the means of
at once exciting a general peritonitis. With 4 states that in the
milder cases the pain disappears in a few days, vomiting ceases,
and within five or six days tenderness and distention disappear.
The bowels open spontaneously a few days after the discon-
tinuance of the opium. They may remain bound for twenty-four
days, yet the general health need not suffer. Recovery may
proceed quietly, steadily, and without* disturbance, and the
appetite return long before the bowels are opened.
1 Ext. Trans. Med. Soc. of Penna, 1SS3.
: Gaz. M£d. dc Paris, :mc S.: 438, 1837.
1 Amer. Med. Times, 3: 258, 1S61.
4 Loc. cit.
^86 Medical Classics
If, after the first twenty-four hours from the onset of the
severe pain, the peritonitis is evidently spreading, and the con-
dition of the patient is grave, the question should be entertained
of an immediate operation for exposing the appendix and deter-
mining its condition with reference to its removal. If any good
results are to arise from such treatment it must be applied early.
Burchard 1 is an enthusiastic advocate of "lumbar typhlotomy
in acute perforating typhlitis.” No surgeon -would hesitate to
give this additional chance for life were he satisfied that per-
foration had actually occurred, and a general peritonitis was
imminent.
If surgical interference is not instituted within the first twenty-
four hours after the onset of the sudden and intense right iliac
pain, to keep the bowels quiet must still be the injunction. The
formation of the tumor, the circumscribing of the peritonitis,
is then to be awaited. It is sure to form, in the large majority
of cases, if the patient lives long enough. It is only in a small
fraction that it occurs before the third day. In more than two-
thirds of the cases the contents will escape externally or inter-
nally. Without surgical aid the escape is into the peritoneal
cavity in most instances, with a rapidly fatal result. In a smaller
number the escape elsewhere not infrequently produces serious
if not fatal sequels.
Iliac abscesses w'ere sometimes incised before the days of
Dupuytren and Grisolle. 2 The latter writer recommended that
they should be opened as soon as fluctuation could be detected,
in opposition to the generally prevailing view that nature should
take its course. It -was left to Mr. Hancock, 3 however, to operate
before this sign could be recognized. He advocated incision
into the tumor in certain stages and forms of mischief, resulting
from the presence of impacted feces or (p. 13c) foreign substances,
in either the caecum or its appendix, which have hitherto, for
the most part, invariably proved fatal. He contended that the
typhoid condition into which patients affected with peritoneal
2 N. Y. Med. Journ., 33: 1, 1881.
2 Arch. Gen. de Med., 4: 314, 1839.
3 London Med. Gaz,, n.s. 7: 547, 1848.
Inflammation of Appendix 487
inflammation fell, did not depend upon the violence of the disease,
but upon the effused fluid, the removal of which he thought the
only chance of saving the patient. His reasons for operating
in the given cases are thus stated: “As she was evidently sinking,
and the previous treatment had been of no avail, I proposed to
make an incision from the spine of the ilium to the inner side
of the internal abdominal ring over the hardened spot, so that
if it were intestine or omentum it could be freed, or if, as was
thought more probable, matter had collected in the right iliac
fossa, it could be let out, and thus give our patient a chance for
recovery.”
Some years later Lewis 1 contributed a paper on abscess of the
appendix, which included an abstract of forty-seven cases, only
one of which recovered. He referred to Hancock’s communica-
tion, and urged the propriety of opening the tumor in case of
threatening urgency even if fluctuation were absent. Willard
Parker, 2 however, deserves the credit of having demonstrated
the success of this operation in three out of four cases, and it is
his advocacy of an early operation which has produced such
favorable results since 1867. He thought surgery useless in
the absence of adhesions, but opportune after the fifth day, when
their presence is probable, and the fear of rupture imminent.
He considered that an incision made between the fifth and twelfth
days was practicable, safe, and justifiable. Even when the
diagnosis was doubtful, “if no abscess had already formed, in
case one should be in process of formation, an external opening
would tend to make it point in a safe direction; and if no abscess
should form a free incision would relieve tension, thus adding to
the comfort of the patient, and in no way prejudicing his safety.”
In 1873, W. T. Bull 3 published an admirable paper on perity-
phlitis, based upon an analysis of sixty-seven cases thus desig-
nated. Thirty-two, nearly forty-eight per cent, terminated
fatally, and in fifteen of these there was perforation of the ap-
pendix. Noyes, 4 in 1882, collected a series of one hundred cases
J N. Y. Joum. of Med., 1:328, 1856.
*N. Y. Med. Record, 2: 25, 1867.
3 X. Y. Med. Joum., iS: 240, 1S73.
4 Reprint from Trans. R. I. Med. Soc. for 1SS2-S3.
488 Medical Classics
of perityphlitis treated by operation, of which eighty were pub-
lished after the appearance of Parker’s (p. 133) paper. Of these,
fifteen died, fifteen per cent of the whole. Even this greatly
lowered mortality might have been diminished by excluding one
case of cancer and another of phthisis. The almost invariable
fatality, in Mr. Hancock’s time, of cases not terminating in
resolution has thus been reduced to less than fifteen per cent
by the general acceptance of a given operation under definite
conditions.
In the table 1 2 which has been prepared to show the day of death
in cases of perforating appendicitis, it appears that 60 out of
176 cases, or 34 per cent, died during the first five days. This
early mortality is sufficiently explained by the consideration of
the table 1 of symptoms indicating the onset of a general peri-
tonitis. It appears that of 73 cases of general abdominal pain,
this symptom appeared during the first five days in 54 instances,
or 74 per cent. Tympanites was noticed during the first period
in 37 out of 38 cases, or 97 per cent. It is thus evident that the
earliest date fixed by Dr. Parker is too late to afford the possi-
bility of relief in more than one-fourth of all the cases. But
early as this date may seem, it has almost universally been the
custom to postpone the time of operating till later in the course
of the disease. The following table is based upon the analysis of
87 cases of typhlitis and perityphlitis. The operation was
performed:
On the
3 ^
day in
I
case
<c
a
5 th
it tt
I
a
n
it
6th
it <«
3 casesf
it
<t
7th
tt <i
3
“ )
K
tt
8th
it tt
7
it
<t
<(
9 th
tt tt
3
tt
u
tt
10th
it cc
11
n
<t
tt
nth
« tt
4
it
u
1:2 th
tt it
4
tt
n
tt
13th
tt tt
6
tt
tt
14 th
it tt
6
a
8=9 per cent.
41 = 47 per cent.
I Page 1 16 .
2 Page 124.
Inflammation of Appendix
On the 15th day in 5 cases
44 41 17th
44 44 1 8 th
41 44 19th
44 44 20th
After 3d week
« 11
<< «<
4
2 "
I case
3 cases
15 = 17 per cent.
23 — 26 per cent.
S7
489
(p. 134) Hence if the indications for operating justified the
election of a date as early as the fifth day, they still more justify
the choice of the third day.
The result has shown the wisdom of the former step, and
the evidence here presented seems not only to warrant, but to
demand the latter. It is evident that the operation to be per-
formed is that of opening the abdominal cavity. It is, therefore,
unnecessary to state that an act which twenty years ago might
have added to the risks of the patient, may at the present time,
when properly performed, be confidently expected to reduce
them very materially.
That the incision of the tumor, in cases of perityphlitis, is
even now frequently omitted, is apparent from the consideration
of the cases of inflamed appendix recently recorded. Of 57 cases
occurring, for the most part, during the past five years, there
were signs of a tumor in 16; an operation was performed in only 7.
The tumor was opened in 4 cases, twice successfully. Laparotomy
was performed as a last resort in 3 instances, the diagnosis being
intestinal obstruction: the cause of the peritonitis was not dis-
covered, and death speedily followed.
Notwithstanding this evidence of a fatal delay in the appro-
priate treatment of cases of appendicitis, the tendency to the per-
formance of an earlier operation is growing. Bull 1 states that he
operated on the third day after the patient was seized with chill,
fever, vomiting, and constipation. There were severe right iliac
pain and increased resistance on pressure. The aspirator showed
pus in the lumbar region, and an abscess was opened behind the
colon. Death occurred two days later, and the autopsy showed
a perforated appendix, paratyphlitis, and general peritonitis.
1 N. y. Med. Record, 29: 267, 1886.
Medical Classics
Barlow and Godlee 1 made an exploratory incision in the median
line on the fifth day. They found early general peritonitis and
lymph near the caecum surrounding a collection of fetid pus,
presumably of appendicular origin. A second incision was made
over the latter. Recovery took place.
Homans 2 operated successfully on the sixth day of the disease,
probably perforation of the appendix, and the second day after
the patient was seen by his physician, Dr. Greene, of Dorchester.
The incision (p. 135) was made into the abdominal cavity over
the seat of pain. The adherent intestines were separated, and
some two ounces of pus removed.
Keen 3 also operated on the sixth day after the occurrence of
sudden, intense, right iliac pain. Although the symptoms had
been characteristic, they were abating. There was increased
resistance, however, dulness on deep pressure, a doughy sensation,
and considerable oedema in the right iliac fossa. The aspirator
showed pus, and a pint was removed after the abscess was opened.
The presence of a general peritonitis does not contraindicate
the operation. The case of Barlow and Godlee shows that the
general peritonitis may have begun yet the patient recover.
Treves 4 operated upon a case of peritonitis of two days duration,
supervening upon an attack of pelvic peritonitis of some three
months’ standing. The patient recovered. Mikulicz 5 operated
on the sixth day after the sudden right iliac pain in a case where
there was evidence of rupture of the abscess into the general peri-
toneal cavity on the fourth day. The wound was closed, slight
improvement followed, but death occurred on the eleventh day.
If the encysted peritonitis becomes general, death has hereto-
fore been almost inevitable. It is thus obvious that if laparot-
omy was successful in two out of three cases where a secondary
general peritonitis was present, there is more than a chance of
recovery by its use even in hitherto necessarily fatal cases. But
1 Med. Times Sc Gazette, 2: $52, 1885.
: Boston Med. & Surg. Journ., 114: 388, 1886.
3 Med. & Sur. Reporter, 54: 165, 1886.
4 Medi co-Chi rurgi cal Transactions, 2 s., i: 175, 1885*
* ^ olkmann s Saroml. klm. Vortr., 262: -313, 1S83.
Inflammation of Appendix 491
it should be employed only when suitable, and not as a last
resort when patients are moribund.
In conclusion, the following statements seem warranted:
The vital importance of the early recognition of perforating
appendicitis is unmistakable.
Its diagnosis, in most cases, is comparatively easy.
Its eventual treatment by laparotomy is generally indis-
pensable.
Urgent symptoms demand immediate exposure of the per-
forated appendix, after recovery from the shock, and its treatment
according to surgical principles.
If delay seems warranted, the resulting abscess, as a rule
intraperitoneal, should be incised as soon as it becomes evident.
This is usually on the third day after the appearance of the first
characteristic symptom of the disease.
THE END
CHARLES McBURNEY
American journal of Surgery, N\S. n, February, 193 1
Charles McBurney
BIOGRAPHY
1845 Born Feb. 17, in Roxbury, now part of Boston, Mass,
of paternal Scotch-Irish and maternal New England
ancestry. Received early education in Roxbury Latin
School and in private schools of Boston.
1862 Age 17. Entered Harvard University.
1866 Age 21. Received degree Bachelor of Arts from Harvard.
1869 Age 24. Master of Arts at Harvard.
1870 Age 25. Doctor of Medicine from College of Physicians
and Surgeons, New York City.
1871 Age 26. Surgical internship of 18 months at Bellevue
Hospital, New York. Rowed almost daily on East
River in single shell. Then took postgraduate study in
Europe.
1873 Age 28. Began practice in New York, associated with
Dr. George A. Peters. Assistant demonstrator of
anatomy at College of Physicians and Surgeons under
Dr. Henry B. Sands.
1875 Age 3°. Attending surgeon, St. Luke’s Hospital. Mar-
ried Mary Willoughby Weston, Oct. 8, the union being
blessed by 2 sons and 1 daughter.
1878 Age 33. Lecturer on Anatomy of Nerves until 1880.
1880 Age 35. Assistant surgeon, Bellevue Hospital.
18S2 Age 37. Lecturer on operative surgery, College of Physi-
cians and Surgeons until 1SS9.
1886 Age 41. Consulting surgeon to Presbyterian Hospital,
New York Hospital and Hospital for Ruptured and
Crippled.
494 Medical Classics
1888 Age 43. Given entire surgical service of Roosevelt Hos-
pital. Held position for 12 years, working m Sims
amphitheatre, a mecca for surgeons from all over the
world. , .
1889 Age 44. Professor of surgery, College of Physicians and
Surgeons until 1894- Described point of maximal
tenderness of abdomen in acute appendicitis (McBur-
ney’s point).
1892 Age 47. Vice-president, New York Academy of Medicine.
Honorary member of College of Physicians and Surgeons
of England. Honorary member of College of Physi-
cians and Surgeons of Philadelphia.
1894 Age 49. Professor of clinical surgery at College of Physi-
cians and Surgeons. Proposed new incision for ap-
pendectomy (McBurney’s incision).
1908 Age 63. Retired because of ill health.
1913 Age 68. Died Nov. 7, at home of sister in Brookline,
Mass., of heart failure following a hunting trip to
Maine. Was an ardent devotee to golf, an expert shot
and salmon fisherman.
Also consulting surgeon to New York, Presbyterian, Orthopedic,
St. Mark’s, St. Luke’s, Ruptured and Crippled Hospitals.
Was also member of New York Surgical Society, Practitioner’s
Society, Roman Medical Society, Fellow of Royal College of
Surgeons of Edinburgh, a corresponding member of the
Societe de Chirurgie of Paris, an honorary member of the
Medical Society of Constantinople.
EPONYMS
1 . Incision: Muscle splitting or gridiron. The incision made in
the abdominal wall in cases of appendicitis , with a description
of a new method of operating. Ann. Surg., 20: 38-43, 1894.
2. Maneuver: Reduction with hooks of the dislocated head of
the humerus m fracture of surgical or anatomical neck;
also called C. B. Porter hook maneuver. Dislocation of the
humerus complicated by fracture at or near the surgical neck ,
Charles McBurnev 495
with a new method of reduction. Ann. Sure., 19: 399-415,
1894.
3. Operation: For the radical cure of inguinal hernia; the sac
is exposed, ligated, and cut oft at the internal ring: the skin
is turned in and stitched to the underlying tendinous and
ligamentous structures. The radical cure of hernia, with
special reference to open treatment of the operation wound.
N. Y. Med. Jour., 47 : 57, 1888.
4. Point: The point of special tenderness in appendicitis: be-
tween an inch and a half and two inches from the anterio
spinous process of the ilium on a straight line drawn from
that process to the umbilicus. Experience with early opera-
tive interference in cases of disease of the vermiform appendix.
N. Y. Med. Jour., 50: 676-684, 1889.
BIBLIOGRAPHY OF WRITINGS
1. Fistula in the anterior portion of the urethra. Med. Rec.,
21: 244, 1882. Also: Illust. Quart. M. & W., N. Y., i:
59-65, 1882.
2. Acute osteomyelitis following slight injury of the ankle.
Med. News, 42: 721, 1883.
3. Tracheotomy as a preliminary to certain operations. Ibid.,
136-139. Also: N. Y. Med. Jour., 37 : 326-329, 1883.
Also: Ann. Anat. & Surg., 7: 201-207, 18S3.
4. Compound comminuted fracture of the skull; absence of
brain symptoms; healing by first intention; recovery.
Med. News, 43: 637, 1883. Also: N. Y. Med. Jour., 38:
610, 1883.
5. Excision of the elbow. Med. News, 45: 721, 1884.
6. Aneurism of the femoral artery; ligation of the external
iliac; cure. N. Y. Med. Jour., 39: 251, 1884.
7. Epithelioma of the larynx. Ibid., 371.
8. Cases of knee joint excision. Ibid., 381 ; 391. Also: Med.
News, 44: 409-412; 424, 18S4.
9. Excision of the knee joint. N. Y. Med. Jour., 41 : 421, 1885.
Also: Med. News, 46: 415-417, 1885.
10. Congenital angioma. N. Y. Med. Jour., 42: 555, 1885.
^6 Medical Classics
11. Two cases of operation for pyloric stenosis. Ibid., 43:
78-80, 1 886. Also: Med. News, 48: 58-62, 1886. Also:
Ann. Surg., 3: 372-380, 1886.
12. Orbital aneurysm. N. Y. Med. Jour., 43: 333> I &86.
13. Fibro-sarcoma of the medial nerve. Ibid., 5°4*
14. Szymanowski’s operation as applied to the cure of urethro-
perineal fistula. Ann. Surg., 4: 461-467, 1886.
15. Case of aneurysm of the innominate artery treated by liga-
ture of the carotid and subclavian. N. Y. Med. Jour.,
45: 191, 1887.
16. Excision of the ankle joint. Ibid.
17. Right inguinal hernia with non-descent of the testis; cas-
tration. Med. News, 1: 613, 1887.
18. Hernia of right ovary; successful removal of gland. Ibid.
19. The radical cure of hernia, with special reference to open
treatment of the operation wound. N. Y. Med. Jour.,
47: 57-61, 1888.
20. Septic peritonitis following perforation of the vermiform
appendix. Ibid., 719-721.
21. Case of traumatic rupture of kidney. Times & Reg.,
Phila., 20: 772, 1889.
22. Experience v r ith early operative interference in cases of
disease of the vermiform appendix. N. Y. Med. Jour.,
50: 676-684, 1889.
23. Contusion of the abdomen w r ith extensive hemorrhage;
laparotomy; recovery. Ibid., 49: 106.
24. The radical cure of inguinal hernia. Med. Rec., 35: 312-
318, 1889. Also ref.: Med. News, 54: 245-247, 1889.
25. Carcinoma of rectum. N. Y. Med. Jour., 49: 355, 1889.
26. Extirpation of thyroid gland. Ibid., 444.
27. Thiersch’s method of skin-grafting. Ibid., 52: 442 -444 ,
1890. Also: Med. News, 56: 427, 1890. Also: Med.
Rec -> 38 : 453~45 6 > 1890. Also : Trans. N. Y. Acad. Med.,
1890, 2. s., 71317 - 331 , 1891.
28. Double hydocele. Med. News, 56: 342, 1890.
29. Chronic abscess of femur. Ibid.
30. Radical cure of inguinal hernia (abstract). Ibid., 343.
Charles McBurney 497
31. Trephining of skull for epilepsy. Ibid., 479.
32. Excision of a spina bifida. Ibid.
33. Excision of a branchiogenic cyst. Ibid., 57:3s.
34. Acute appendicitis. N. Y. Med. Jour., 52: 329, 1S90.
35. Recurrent appendicitis. Ibid.
36. Osteosarcoma of the left scapula; tumor of thyroid gland;
Thiersch’s method of skin-grafting. Intcrnat. Jour.
Surg., 3: 286, 1S90.
37. Suprapubic section. N. Y. Med. Jour., 53: 309, 1S91.
38. The indications for early laparotomy in appendicitis.
Ann. Surg., 13: 233-254, 1891.
39. Trephining for traumatic aphasia; recovery. N. Y. Med.
Jour., 53: 517, 1891.
40. Section of the intestine for removal of gall-stone. Ibid.,
520.
41. Discussion on appendicitis; indications for early operation.
Trans. Med. Soc. N. Y., p. 208, 1891.
42. Contribution to Dennis’ System of Surgery.
43. Contribution to International Textbook of Surgery.
44. Traumatic hemorrhage from a vein of the pia mater; com-
pression of Broca’s convolution and of the sensorimotor
area of the cortex; aphasia; partial hemiplegia and hemi-
anesthesia; trephining; removal of clot; recovery. With
Starr, M. A. Brain, London, 14: 284-288, 1891.
45. Cases of appendicitis, illustrating different forms of the
disease. Med. Rec., 41 : 421-427, 1892. Also: Trans.
N. Y. Acad. Med., 1892, 2. s., 9: 79-109, 1893.
46. Osteoplastic resection of the upper jaw for nasopharyngeal
polypus. N. Y. Med. Jour., 55: 580, 1892.
47. Osteosarcoma of the jaw. Ibid.
4S. Traumatic epilepsy, operated upon. Med. & Surg. Re-
porter, 66: 881, 1892.
49. Trephining for cranial injury. Med. Rec., 42: 742, 1892.
50. Fibrosarcoma of cerebellum and pons. With Starr, M. A.
Ibid., 43: 87.
51. Glioma of cerebellum. Ibid., 88.
52. The treatment of general septic peritonitis due to appendici-
tis. Ann. Surg., 18: 42-48, 1S93.
49 B Medical Classics
53. A contribution to cerebral surgery. Diagnosis, localization,
and operation for removal of three tumors of brain; with
some comments upon the surgical treatment of brain
tumors. With Starr, M. A. Am. Jour. Med. Sc., n.s.,
105: 381-387, 1893. Also: 22 pp., 8°, Phila., 1893.
54. The incision made in the abdominal wall in cases of ap-
pendicitis, with a description of a new method of operat-
ing. Ann. Surg., 20: 38-43, 1894.
55. Cyst of the pancreas. Ibid., 19: 492.
56. Dislocation of the humerus complicated by fracture at or
near the surgical neck, with a new method of reduction.
With Dowd, C. N., Ibid., 399-415; 493-497. Also:
17 pp., 8°, Phila., 1894.
57. Cases illustrating the use of a mechanical appliance to
correct the deformity after removal of half of the lower
jaw. Ann. Surg., 20: 35-37, 3 pi., 1894.
58. Sarcoma of kidney. Ibid., 373-376.
59. Chronic dislocation of shoulder with fracture reduced by
hooks. Ibid., 21: 299-301, 1895.
60. Sarcoma of ovary in a girl aged ten years. Ibid., 706.
61. Rupture of quadriceps extensor tendon. Ibid., 22: 506-508.
62. Fracture of the pelvis. Trans. Amer. Surg. Assn., 13:
5 ° 3 - 5 ° 5 > i 8 95 -
63. Epithelioma of the tonsil. Ibid., 505.
64. Traumatic popliteal aneurysm. Ibid., 506.
65. Sarcoma of radius. Ibid.
66. Suture of quadriceps tendon. Ibid., 507.
67. Removal of the lower jaw. Ibid., 508.
68. Appendicitis. Ibid.
%• Treatment of the diffuse form of septic peritonitis occurring
as a result of appendicitis, with cases. Med. Rec., 47:
385-390, 1895.
70. Fracture of the humerus associated with dislocation of the
shoulder joint. N. Y. Polyclin., 5: 72-75, 1895.
71. Carcinoma of breast. Med. News, 68: 269, 1896.
72. Acute appendicitis. Ibid., 270.
7 3 - The treatment of appendicitis. Ibid., 69: 653-656. Also:
n PP-> 12 0 , N. Y., 1896. ^ *
Charles McBurney 499
74. Non-recurrence of sarcoma of naso-pharynx three years
after operation. Med. Rec., 49: 204, 1896.
75. Non-recurrence of cancer of tonsil three years after opera-
tion. Ibid.
76. Surgical treatment of appendicitis. Dennis’ System of
Surgery, 4: 4 I 5“433 > i8 9 6 -
77. Speech at sixth annual dinner of Harvard Medical Alumni
Association. Boston Med. & Surg. Jour., 135: 316-322,
1896.
78. The surgery of the future. Ibid., 384.
79. Inguinal hernia and varicocele. Internat. Jour. Surg.,
9: 41, 1896.
80. Inguinal hernia, Bassini’s operation. Ibid., 43.
81. Separation of the upper epiphysis of humerus; open opera-
tion. Ann. Surg., 23: 177-180, 1896.
82. Sarcoma of radius; amputation of forearm by a new method.
Ibid., 181-183.
83. Nephrectomy for displaced kidney and hydronephrosis.
Ibid., 183-185.
84. Nephrectomy for abscess of kidney. Ibid., 282.
85. Successful resection of small intestine for sarcoma with
intussusception. Ibid., 441-444.
86. Reduction of dislocation of the humerus complicated by
fracture at the anatomical neck; operative treatment of
separation of the lower epiphysis of the femur. Ibid.,
510-519.
87. Operative treatment of carcinoma of the breast. Ibid., 607.
88. Appendicitis obliterans. Ibid., 608.
89. Result of Halsted’s operation for carcinoma of breast.
Ibid., 25: 363, 1897.
90. Direct intra-abdominal finger compression of the common
iliac artery during amputation at the hip joint. Ibid.,
610-613; 714.
91. The treatment of appendicitis. N. Y. Polyclin., 9: 1-5,
i8 97-
92. The surgery of the future. Semi-Centen. Anesthesia,
Boston, pp. 69-76, 1 897.
jjoo Medical Classics
93 Is not the mortality from surgical disease larger than
necessary? Med. Rec., 5a: 881; 894-896, 1897. Also:
Canada Lancet, 30: 328-330, 1897.
94. A case of carcinoma of the tonsil. Med. Rec., 52: 893, 1897.
95. Cancer of the breast. Internat. Jour. Surg., 11: 144, 1898.
96. Cancer of the lip. Ibid., 47 •
97. Epithelioma of the lower lip. Ibid., 144.
98. Recurrent appendicitis. Ibid., 308-310.
99. Vesical calculus. Ibid., 145*
100. Aneurism. Ibid., 146.
101. (Superficial sarcoma over right clavicle.) Ibid., 307.
102. (Recurring appendicitis.) Ibid., 308-310.
103. Traumatic rupture of spleen; extirpation. Med. Rec.,
53: 601, 1898.
104. Use of rubber gloves in operative surgery. Ann. Surg.,
28: 108-119, 1898.
105. Aneurism of the external iliac artery; treated by ligation of
common iliac. Ibid., 128.
106. Amputation at hip joint for recurrent sarcoma. Ibid.,
129-131.
107. Complete resection of clavicle for osteosarcoma. Ibid., 259.
108. Plastic operation for deformity of nose. Ibid., 258.
109. Removal of biliary calculi from the common duct by the
duodenal route. Ibid., 481-486.
1 10. The technic of aseptic surgery. Internat. Text-book Surg.,
i: 263-305, Phila., Warren & Gould, 1899.
hi. Recurrent appendicitis; tuberculous disease of the knee
joint. Internat. Jour. Surg., 13: 244-246, 1900.
1 12. Remarks concerning the practice of aseptic surgery. N. Y.
Med. Jour., 75: 490-496, 1902.
113. The surgical treatment of hemorrhoids. Ibid., 81: 417-
422, 1905.
114. Amputation at hip joint for tuberculosis. (Case report)
Med. Rec., 73: 667, 1908.
BIBLIOGRAPHY OF BIOGRAPHIES
Obituary. Brit. Med. Jour., 2: 1413; 1465, 1913.
Obituary. Jour. Amer. Med. Assn., 61 : 1826, 1913.
Charles McBurney 501
Obituary. Lancet, Lond., 2: 1502, 1913.
Obituary. Med. Rec., 84: 903, 1913.
Obituary. Physicians & Surg., 35: 521-523, 1913.
Obituary by Johnson, A. B. N. Y. Med. Jour., 98: 978, 1913.
Historical sidelights on appendicitis. (Letters from C. McBur-
ney) Med. Life, 29: 332-336, 1922.
Master surgeons of North America: Charles McBurney. By
Peck, C. H. Surg., Gynec. & Obst., 36: 430-432, 1923.
Contributors to the science of medicine: Charles McBurney.
Med. Jour. & Rec., 99: 208, 1924.
Eponym: McBurney’s point. Amer. Jour. Surg., 8: 728, 1930.
McBurney’s point, Ibid., 11 : 364, 1931.
INDEX TO BIBLIOGRAPHY
Reference
Year
Abdominal hemorrhage
2 3
On
00
00
>— 1
Aneurism
6
1884
15
1887
64
1895
100, 105
1898
" orbital
12
1886
Angioma
IO
1885
Ankle, excision of
16
1887
Aphasia, traumatic
39) 44
1891
Appendicitis
20
1888
22
1889
34> 35
1890
3 8 > 4*
1891
45
1892
5 2
1893
54
1894
68, 69
T- ) 13)
1 895
76, 88
1896
9 1
1897
98, 102
1898
101
1900
5 02
Medical Classics
Branchiogenic cyst
Breast, carcinoma of. .
Calculi, biliary
“ vesical
Cerebellum, tumors of
Clavicle, sarcoma of. .
Cranial injury
“ surgery
Elbow, excision of . . . .
Epilepsy
Femur, abscess of . . . .
Gall-stone in intestine
Hemorrhoids
Hernia, inguinal
Hip joint, amputation of
Humerus, fracture and dislocation of
Hydrocele
Intestine, sarcoma of
Jaw, operation on
Kidney, abscess of
rupture of
sarcoma of
surgery of
' Knee, excision of
Reference
Year
33
1890
7 h 87
1896
89
1897
95
1898
109
1898
99
1898
S °> 5 1
1892
101, 107
1898
49
1892
53
5 893
5
1884
3 i
1890
48
1892
29
189O
40
189I
n 3
I905
1 7
1887
*9
1888
24
1889
3 °
189O
79, 80
1896
90
1897
106
CO
CO
1 14
1908
5 6
1894
58, 70
*895
81, 86
1896
28
1890
85
1896
57
1894
67
1895
84
1896
21
1889
58
1894
83
1896
8
1884
9
1885
Charles McBurney 503
Reference Year
Larynx, epithelioma of 7 1SS4
Lip, cancer of 96,97 1898
Mortality, surgical 93 1897
Naso-pharynx, sarcoma of 74 1896
Nerve, median 13 18S6
Nose, plastic operation on 10S 1898
Osteomyelitis 2 1883
Osteosarcoma, of jaw 47 1892
“ of scapula 36 1S40
Ovary, hernia of 18 1887
“ sarcoma of 60 1895
Pancreas, cysts of 55 1S94
Pelvis, fracture of 62 1895
Quadriceps extensor, rupture of 61, 66 1895
Radius, sarcoma of 65 1895
82 1896
Rectum, carcinoma of 25 1889
Rubber gloves in surgery 104 1898
Skin grafting -7,36 1890
Skull, fracture of 4 1883
Spina bifida 32 1890
Spleen, rupture of 103 1898
Stomach, pyloric stenosis 11 1886
Suprapubic section 37 1891
Surgery, aseptic no 1899
1 12 1902
Szymanowski’s operation 14 1886
Thiersch’s skin graft 27, 36 1890
Thyroid, operation 26 1889
Tonsil, epithelioma of 63 1895
75 i8 9 6
94 1897
Tracheotomy 3 1883
Urethral fistula 1 1882
14 1886
Vesical calculus 99 1898
McBURNEY’S POINT
One of the mile-stones along the road of revelation of the true
nature of appendicitis must bear the name of Charles McBurney.
Before him, of course, in time and importance, arc the names of
Fernal (1554), Hesiter (1711), Mestivier (1759), LaMotte (1766),
James Parkinson (1812), Villermay (1824), Melier (1827). ar id
others down to Reginald H. Fitz of Boston who first established
the true pathologic process and applied the term appendicitis in
1886. McBurney’s first paper on this disease appeared two years
later, Septic peritonitis following perforation of the vermiform
appendix. N. Y. Med. Jour., 47: 719-721, 1888. Every year
thereafter for a decade there was at least one paper on appendicitis
published by this surgeon who had entire charge of the surgical
service at Roosevelt Hospital and was Professor of Surgery in the
College of Physicians and Surgeons in New York City.
For recognizing the light given by Fitz, for studying and report-
ing cases of appendicitis, and for passing on the light to others,
posterity has “rewarded” McBurney by attaching his name to
one of the most common signs of the disease, a point of tenderness
in the right lower abdominal quadrant.
The paper announcing this clinical sign is entitled Experience
with early operative interference in cases of disease of the vermiform
appendix. N. Y. Med. Jour., 50: 676-684, 1889. See the follow-
ing pages for the complete paper. The author was very specific
in locating the point of greatest tenderness, placing it, as “deter-
mined by the pressure of one finger,” — “very exactly between an
inch and a half and two inches from the anterior spinous process
of the ilium on a straight line drawn from that process to the
umbilicus.”
After McBurney, several other authors brought forth their
pet points of maximum tenderness in acute appendicitis, but many
of these authors we must accuse of desiring to equivocate or to
attract attention. Many writers argue that since the location
of the appendix is not fixed, the point of maximum tenderness
must vary. However, pain on pressure at McBurney’s point is
explained by reflexly irritated nerve endings of the eleventh and
twelfth dorsal segments on the anterior abdominal wall. The
same nerve segment is always irritated so that the point remains
fixed no matter in which direction the diseased appendix may
extend.
Many recent authors have incorrectly described the location
of McBurney’s point. Thus Osier in Practice of Medicine , 7th
edition, page 515, and 9th edition, page 524, and Dean Lewis
in Cecil’s Textbook of Medicine , 1st edition, page 71 1, place McBur-
ney’s point at the middle of a line joining the umbilicus and right
anterior superior spine. Bailey, deQuervain and Sloan do not
mention the point at all, much less give it its proper name. Mur-
phy, Rose and Carless, Romanis and Mitchincr, Ashhurst, Da-
Costa, Royster, Livingston and Donhauser describe the point cor-
rectly.
If we persist in using eponyms in medicine (and we should),
our application of them must be limited to the exact condition
originally described. Perhaps the unavailability of the original
paper has been a large factor in inaccurate reference. To supply
these originals is the purpose of this publication.
Experience with Early Operative
Interference in Cases of Disease
of the Vermiform Appendix
BY
CHARLES McBURNEY, M.D.
Visiting Surgeon to the Rooseoelt Hospital, hrz 1 erk City
Read before the New York Surgical Society, Nov. 13, 1889
Published in the New York Medical Journal, 50: 676-6S4, 1S89
VENTURE to introduce once more a subject
that has been so ably treated by numerous
writers, because I have for some time been
devoting my attention in suitable cases to a
particular line of treatment, and because I have
been fortunate enough to have had recently
a considerable number of cases of disease of the appendix under
my care. Nearly two years ago the account of a case of successful
laparotomy for perforation of the vermiform appendix was read
before this society by our much-lamented colleague, Dr. Henry
B. Sands. The case was a most brilliant one throughout, and
illustrated particularly well the cleverness of diagnosis and the
rapidity of successful action which we all remember as so char-
acteristic of the reader of that paper. It should not be forgotten
that at that time such action was a very bold step into ground
506
McBurney’s Point 507
that was almost unknown. We did not all agree with Dr. Sands
in the views which he expressed in regard to the pathology of
perityphlitis, but these views did not prevent him, when the
proper case occurred, from making, in regard to treatment, a
brilliant stride in advance of others. This case gave an impulse
to the study of inflammatory affections of the vermiform ap-
pendix from which we shall not recover for a long time. During
the following months Dr. Sands devoted much attention to
this study, and it was my privilege to assist him in a number of
successful operations for the removal of the appendix at an early
stage of disease. It seemed to me that each one of these opera-
tions shed a flood of light upon the pathology of the so-called
pericecal inflammations, and during the summer following, while
discussing the subject, he expressed to me views which were far
in advance of most surgeons and very different from those which
he entertained at the time when he wrote his last paper. If he
were here to-night he would, by the results of his own last year’s
original work, enlighten us upon many points respecting the
pathology of perityphlitis. I feel it a pleasure and a duty to
thus refer to Dr. Sands, because, unfortunately, no special record
has been kept of his last year’s brilliant work, and his sudden
death prevented him from telling us himself what would have
been so valuable. Certainly no other surgeon ever did so much
to improve the treatment of a very fatal disease. Beginning with
the first suggestion of Dr. Willard Parker, which taught surgeons
how to save many lives, although by a slow and often unsatis-
factory process. Dr. Sands ended his work in this direction by
showing us how we might cut short at its very inception a disease
that is even to-day responsible for many deaths.
It is not my intention in this paper to attempt to present the
subject of pericecal inflammation in a systematic manner. That
has already been done, and very recently, by a large number of
writers. I have chosen rather to dwell upon some points in the
pathology and treatment of these inflammations, which are
beginning to be better understood and which especially interest
us all. The fact that inflammatorv affections of the vermiform
*
appendix give rise to a considerable number of the so-called
^ 0 g Medical Classics
pericecal inflammations is now accepted in every part of the
medical and surgical world, although one still reads of perityph-
litis and paratyphlitis, and of intraperitoneal and extraperi-
toneal abscesses. Certainly ail of these terms are misleading,
inasmuch as each of them, when used without explanation,
implies that the particular disease to which it refers is a disease
by itself, and fundamentally different from the others. The
usual term perityphlitis means, strictly speaking,^ nothing more
than an inflammation of the peritoneum surrounding the cecum,
but it is understood by many to mean often a localized and harm-
less peritonitis arising from impaction of feces, by others a fatal
septic disease originating in perforation of the appendix. Now
it is unquestionably true that every case of inflammation of the
appendix is sooner or later accompanied by inflammation of
the neighboring peritoneum, either on the cecum or mesentery
or ileum, etc., but if from the whole list of acute inflammatory
affections occurring in the right iliac fossa we set aside those
originating in the appendix, how many shall we have left? Very
rarely will occur a perforation of the cecum by ulcer or foreign
body, giving rise to a local peritonitis at this point, and trau-
matisms from without may accomplish the same result. For
all of such causes as compared with inflammations of the ap-
pendix, let me hazard the proportion one in one hundred.
How many cases of localized peritonitis or perityphlitis arise
from impaction of feces in the cecum ? Some writers would lead
us to believe that this is a frequent cause, and not long ago it
was looked upon as the most frequent cause. Is there a single
observation brought from the dead-house or from the operating-
table to support this idea? I have never heard or read of such
observation, and I do not believe that any such case ever oc-
curred. Clinically we meet with cases of pain in the right iliac
fossa, accompanied by some rise of temperature, and not infre-
quently m these cases we may detect masses of feces in the
cecum, ut no peritonitis exists, and it is no more likely to arise
from this cause than from ordinary constipation, which often
causes pain and rise of temperature. Correctly speaking, then,
pernomtis localized m the immediate neighborhood of the cecum
McBurney’s Point 509
and characterized by the well-known symptoms may, with the
rare exceptions referred to, be attributed to an inflammation of
the vermiform appendix in some one of its numerous stages.
This inflammation may be a comparatively mild catarrhal one,
affecting little more than the mucous membrane, or it may have
rapidly passed through various stages to complete gangrene of
the organ. I must therefore prefer to use the term inflammation
of the appendix, or appendicitis, and give up, once and for all,
the terms perityphlitis, paratyphlitis, extraperitoneal abscess,
etc., as misleading and not valuable except in explanation of
secondary (p. 677) pathological processes. In regard to the
so-called extraperitoneal abscess as a result of inflammation of
the appendix, there remains nothing to be said to any one who
has read Dr. Wier’s admirable paper in the “Medical News”
for April 27th of this year. The statements and observations
which Dr. Wier there makes are perfectly convincing, and I
have often confirmed many of them during an operation. As
a late result of a much-neglected case, pus may force its way
through the lateral or posterior peritoneal lining of the abdomen,
but even in very old cases this must be a rare condition, and I
have myself never met with such a one. All of these abscesses
originating in inflammation of the appendix are intraperitoneal.
Inflammatory adhesions, which glue together the adjacent coils
of intestine, prevent the contents of the abscess from flowing
into the pelvis or among the intestinal folds. At every point
the pus is bounded by peritoneum. All of the operations done
by the Willard Parker method require section of the peritoneum
which forms the anterior wall of the abscess. I have dwelt upon
this point because it is a very important one, and one’s views in
regard to it will determine his operative methods. In this con-
nection I must refer to two other terms — extraperitoneal abscess
and extraperitoneal incision for the opening of such abscesses.
These again are very misleading, and imply that uninflamed
peritoneum can be pushed away from the iliac fossa, the connec-
tive tissue broken through, and the abscess evacuated. If these
abscesses are, as I have stated, all (with possibly a very rare
exception) intraperitoneal, then, of course, these terms are false
^io Medical Classics
and misleading. The peritoneum may be pushed back and the
abscess incised deep in the iliac fossa by a roundabout and un-
surgical method, but when incised the peritoneum will be cut.
In the present state of surgical opinion, it remains with those
who claim that they meet with extraperitoneal abscesses and
make extraperitoneal explorations to prove their point. In not
a single one of the early operations for appendicitis which I
have done and seen done has there been the slightest doubt as
to the fact that the incipient abscess was entirely within the
peritoneal cavity. I mean that this fact has always been de-
monstrable to the satisfaction of every one present. This one
must consider as a valuable piece of evidence, for the observations
were made at a period in the disease when there could be no
obscurity as to the actual condition present. Weir has clearly
shown also, in the paper already referred to, by carefully analyzing
the reports of one hundred autopsies, that in no one of them did
the abscess originate in the extraperitoneal tissue, and that in
only four was pus found there at all. Weir also states, when
referring to the difficulty of demonstrating the intra peritoneal
origin of these abscesses after a considerable abscess has formed,
that in only eight out of twenty-six abscesses opened by him
could he “recognize that the inner wall of the abscess was made
up of loops of intestine bound together by adhesions.” But,
as I have already said, no difficulty is found in making this demon-
stration when an operation is done at an early stage of the disease.
In these early operations I have found a very varied condition
of the appendix and its surroundings, from a mild catarrhal con-
dition of the mucous membrane accompanied by some infiltration
and thickening of the submucous and other tissues, to the state
of complete gangrene of the whole organ, with more or less
extensive peritonitis.
In one instance I removed the appendix from a young lady
who in the course of little over a year had had no less than twelve
attacks of so-called perityphlitis. These attacks had been severe,
giving rise to great pain with rise of temperature, and causing
alarm not only to the members of her family, but to her medical
attendants, two of these at least being as careful observers as
McBurney’s Point 5 1 1
exist in New York. The operation was done during a period of
complete health and after careful consultation, to prevent re-
currence. The appendix was found rigid and swollen, the mucous
membrane mildly inflamed, the other tissues of its walls greatly
thickened. Not the slightest evidence of peritoneal inflammation
or adhesion existed. The appendix was readily removed and
the patient made a rapid recovery. The operation was done
nine months ago. Since that time the patient has enjoyed
unbroken health, has resumed active exercise, and has gained
twenty pounds in weight. In another case, also a young lady,
attacks of abdominal pain, accompanied by vomiting, exquisite
tenderness in the right iliac fossa, and considerable elevations of
temperature, had occurred on four different occasions. This
patient had also been taken care of by the most competent men.
Curiously enough, just at the time of this patient’s last attack
her sister died without operation from a violent purulent peri-
tonitis caused by perforation of the appendix. Subsequently to
this last attack and during a period of complete health I removed
the appendix after careful consultation with her physician. Dr.
J. W. McLane, to prevent recurrence. A condition of disease
somewhat in advance of the case already narrated existed. The
appendix was quite firmly bound by old adhesions to the under
surface of the intestinal mesentery and to the cecum. The
mesentery of the appendix had been nearly obliterated; the
organ itself was dark-colored, considerably swollen, but soft.
The mucous membrane was very dark-colored and swollen, and
inclosed some fine fecal grains. Two partial strictures of caliber
existed which produced retention of a dirty brown fluid. The
evidences of former limited peritonitis existed on the neighboring
portion of the cecum. This patient also made a rapid recovery,
being out of bed at the end of two weeks, with a wound com-
pletely healed. The operation was done over four months ago,
and the patient had remained in perfect health, having gained
largely in weight and having resumed active exercise from which
she had been entirely debarred. These two cases are quoted at
this point to show that comparatively slight conditions of in-
flammatory disease in the appendix may give rise to threatening
£12 Medical Classics
illness, which by some would be described as resolving perityph-
litis without further explanation. There can be little doubt
that both of these cases were preparing for abscess or general
peritonitis.
In other cases — all in an acute stage of inflammation and
which will be quoted later, the conditions found have been these;
In one the appendix formed a considerable cyst containing
nearly an ounce of dark-brown pus. No communication with
the cecum existed.
(p. 678) In several the appendix was swollen, discolored,
diseased throughout, but gangrenous only at one or two points
where perforation had occurred, and in these cases one or more
fecal concretions existed, either within or just outside of the
appendix.
In several the appendix was in general only moderately dis-
eased, but perforation had occurred, and quite firm recent ad-
hesions had tied the appendix to some adjacent part, doubling
it upon itself and so inclosing a small collection of pus with or
without concretion.
In two cases the appendix was thick, but flattened so as to be
with difficulty recognized, and very firmly bound to the under
side of the cecum, and in two cases the appendix was completely
gangrenous. In all of these acute cases peritonitis existed —
usually a plastic peritonitis of greater or less extent — always
involving the cecum and generally the adjacent intestinal coils
and abdominal walls. In one case the omentum was quite
extensively involved, partly enveloping the appendix. In no
case was the appendix more than lightly attached by adhesion
to the peritoneum covering the iliac muscles, and in none was
eW/wperitoneal inflammation observed, excepting sometimes in
the anterior abdominal wall. In most cases some pus was found
more or less confined by adhesions within a limited area, and in
one absolutely no adhesion of any kind existed, though the
appendix was perforated by concretion, and very foul pus filled
the pelvis and ran freely upward beside the colon.
The pathological conditions of the appendix, as compared
with the symptoms in my own cases, most positively show that
McBurney’s Point 513
one can not with accuracy determine from the symptoms the
extent and severity of the disease. I therefore doubt the safety
of the advice given by several recent writers, to watch the symp-
toms and to be guided by their violence in determining the
method of treatment. This will appear more clearly in the
histories of the cases. I should like now to refer to some of the
special symptoms the weight and value of which have been sub-
sequently determined by an immediate operation , for it is in this
manner that we shall mostly advance our knowledge of the
pathology of appendicitis. By autopsy we can not learn very
much more in this direction if one may judge by the length of
time it required to learn the important single fact that abscesses
originating in the appendix are almost invariably intraperitoneal.
Pain to a greater or less extent is present in all cases of appen-
dicitis, but many a mistake has been made and a golden oppor-
tunity lost by looking for pain in the iliac fossa and an absence
of pain in other parts of the abdomen. General abdominal pain
is often all that the patient will complain of in the first few hours
of his attack, and in many cases it requires a careful and pointed
examination to determine that the cause of the pain is situated
in the iliac fossa. But after the first few hours it becomes more
and more evident that the chief seat of pain is at that point,
and the general pain then usually subsides. The epigastric
region is frequently the point first complained of. One patient,
who died on the third day from violent septic peritonitis from
perforation, complained of comparatively little pain even when
the iliac fossa was firmly compressed. The exact locality of the
greatest sensitiveness to pressure has seemed to me to be usually
one of importance. Whatever may be the position of the healthy
appendix as found in the dead-house — and I am well aware that
its position when uninflamed varies greatly — I have found
in all of my operations that it lay, whether thickened, shortened,
or adherent, very close to its point of attachment to the cecum.
This, of course, must, in early stages of the disease, determine
the seat of greatest pain on pressure. And I believe that in
every case the seat of greatest pain, determined by the pressure
of one finger , has been very exactly between an inch and a half
Medical Classics
and two inches from the anterior spinous process of the ilium
on a straight line drawn from that process to the umbilicus.
This may appear to be an affectation of accuracy, but, so far as
my experience goes, the observation is correct.*
Chill and vomiting are frequent, but so often absent as to be
in no sense of much diagnostic value. Fever to some extent
is present in all cases, but very different in degree, some severe
cases having a temperature on the first day of less than 100.5°,
others rapidly reaching a temperature of 103. 5 0 . But, as nearly
excluding non-inflammatory pains, the presence of this symptom
is certainly of importance. Rigidity in the abdominal muscles,
generally much more marked on the affected side than on the
other, I have found very constant, and I believe it to be a sign
of value.
Abdominal distension by tympanites varies greatly, and its
degree by no means measures the severity of the diseased process.
It may be very decided during the very first hours of a mild case,
and also entirely absent in the worst form of sudden perforation.
It must, of course, be influenced greatly by the condition of the
patient's bowels, the ease with which the intestine in each in-
dividual is brought to a state of paresis, and by many other
causes. But when the gut has been found during the operation
to be overdistended, the portion of gut so affected has always
been the large intestine. Probably pareses from the local peri-
tonitis is here a large factor.
Tumor of greater or less size I have usually been able to
detect at a very early stage, but the composition of this tumor,
as shown during operation, has varied greatly. In one case the
tumor consisted of the distended unruptured appendix, which
was partly wrapped in an inflamed and thickened omentum.
In another it was formed of a mass of intestinal coils swollen and
glued together by recent plastic exudation. This tumor was
large, quite firm, and gave one the impression that a large quan-
tity of pus was present; but only a very minute abscess was
* Since reading this paper I have carefully observed three other cases. In two the
point of pan shown by pressure with one finger was two inches, and in the other an inch
and seven-eighths from the anterior spine.
McBurney’s Point 515
found, and that was situated quite beneath the cecum. But
under ether some tumor can invariably be detected; and this
agent will, I think, be found to be a valuable help to diagnosis
in some doubtful cases. The tumor may be dull on percussion,
as when pus has formed and lies against the anterior abdominal
wall; but I have more than once found a small deep tumor con-
taining pus, which was so completely (p. 679) covered in front
by intestines that the percussion note, before ether was given,
was purely tympanitic. The pulse during the onset of appen-
dicitis is usually rapid and irritable. The patient prefers to
have the right thigh elevated, and objects to its overextension.
Rectal examination at the onset I have not found of any value.
The combination of symptoms present will usually render
a correct diagnosis as to the seat of the disease quite easy, but
in reference to the stage which the disease has reached — that is,
whether pus has formed or not, whether the appendix is already
perforated or not, even sometimes whether already general septic
peritonitis exists or not — the diagnosis is often very doubtful.
I remember one case where Dr. Sands performed a beautiful
operation and saved the patient’s life. At the consultation
held before operation four gentlemen were present. Three of
them had certainly seen many cases of appendicitis. Three
quite different opinions were expressed. Dr. Sands thought
that the appendix was perforated, and that pus had formed.
One of the others thought that there was probably appendicitis,
but advised an extraperitoneal incision. Another thought the
case so mild that it should be treated without operation. Dr.
Sands operated by an incision along the right edge of the rectus
muscle, opened an intraperitoneal abscess just in the middle of
his incision, and removed a perforated and sloughing appendix.
The patient rapidly recovered. This case occurred very shortly
after Dr. Sands read his last paper before this society. I mention
it to show that the diagnosis of the exact condition in such cases
is not easy. A means of diagnosis lauded by some, permitted
by others, and totally condemned by a few, is the exploring
needle. I believe that the use of this instrument will become less
and less frequent as we know more of the disease. While perhaps
, A ; ca l Classics . \ s cer-
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information,^ V . s td\ ^ pto ms P r °J U ^tlon, and
1 thinh that there the symp . K t hts concn - te
J* any Practtaoners as w *x*cJ* e fcease ^
Inoftteawcnd.^ ^ onset ^ ^ less .sever* ^
-witVi no o e ’ to ms, as com? 4 Xhe whether
a"®—*? oU slondy fo^oels can te made as ^ wb ere
niencemen accurate d g exC eptmg ® l , ag&ravated,
the early stag _ > r f ora ted or no , become muc ® S - m f er red.
the appendix ' J? u symT toms ^ £ absce ss may ^ ^ vety
comparatree'y Ae rupture ' symptoms form adon
trhen pcr fora “ f “ occurs «th tet 4 by the > in .
Perforatmn oten bel ng p niix , no sud
be g,„nmg o *e adbesl on ot th
of more or les V
McBurney’s Point 517
crease in the severity of the disease occurs at all. An abscess
slowly forms, which may increase to a considerable size without
being discovered, and then force its way, or proceed by infection,
in the most dangerous directions. The comment might fairly
be made upon this description of the early symptoms of appen-
dicitis that the diagnosis of the disease is very obscure and
uncertain. To the careful observer it is not difficult, however,
to determine as to the existence of the disease. The only real
difficulty lies in determining within the first few hours what the
future progress of the disease is to be in deciding whether firm
adhesions are forming, which will effectually exclude pus from
the general peritoneal cavity, and so provide for subsequent safe
evacuation of abscess, or whether no such protecting wall exists,
and an overdistended appendix threatens to instantly set up a
fatal peritonitis. If this difficulty could be set aside by a more
careful study of symptoms, and without losing valuable time,
our course would be clear, and we should no longer helplessly
hesitate as to when to operate and when to stand aside. There
is no reason to think, however, that diagnosis from symptoms
alone will ever reach that perfection. We need some further
aid to diagnosis; some positive and rapid means of determining
what method of treatment we are to adopt. We have reached a
point where we can never be satisfied with the mortality that
attends an expectant treatment. What we wish to accomplish
in the treatment of appendicitis is, not to save half of our cases,
nor four cases out of five, but all of them ; and how is this end to
be attained except by improved methods of diagnosis at the
very earliest stage of the disease ? I hope that I may never again
go every day to visit a threatening case, waiting bashfully for
the authority of a clearly defined general peritonitis before I
dare take action. I do not mean to deny that many very ugly-
looking cases of appendicitis go on to the formation of abscess
which may be safely opened and end in complete recovery; we
have all of us seen many such. I am well aware that numerous
cases have presented all the symptoms of the disease, have become
very ill, and have finally recovered without any operation. Within
two years I have seen two cases, in one of which the patient was
5x8 Medical Classics
so ill that I refused to operate, and in the other case I strongly
urged operation and was refused permission. Both of these
patients recovered after long illness without (p. 680) operation
of any land. Probably the abscesses emptied themselves . at
some point into the intestine. But such unexpected recoveries,
and the frequent formation of abscesses which can be opened
safely at a later stage, even the many cases which quite rapidly
terminate, at least temporarily, without suppuration, do not
console us for the heavy mortality caused by appendicitis. What
this mortality has been we shall of course never know. We do
know that the cases which are recognized and which die are
numerous, and it is safe to assert that a very large number of
fatal cases of peritonitis commence with an unrecognized inflam-
mation of the vermiform appendix. No one will dispute that if
we could so improve our methods of diagnosis that we could
recognize within the first few hours the serious nature of many
cases, we would operate in these cases at once, willingly preferring
to incur the risks of an operation rather than face the certainty
of death that septic peritonitis implies. How may we improve
our methods of diagnosis? At present I see no clearer road than
the exploratory incision permitting a direct inspection of the
parts and a complete study of the disease. If it can be shown by
future experience with improved methods of operation, and with
more perfect antiseptic precautions, that the exploratory incision
for the inspection of the diseased appendix is much more free
from danger than the expectant treatment, then there could be
but one answer to the question, What is the best treatment?
The firm conviction that very early operation for the cure of
appendicitis can, with proper care, be done with very slight risk,
has induced me to subject a considerable number of these cases
to the earliest operation possible, and my chief purpose to-night
is to present to you the results of my work in this direction. It
is proper to state that no case of appendicitis has been refused
operation, and that all the cases operated upon in the early state
of the disease are here reported:
Case I.-— E. M. P., a young gentleman nineteen years of age, com-
plained of general abdominal pain at n A.M, on May 21, 1888. The
McBurney’s Point 519
pain was regarded as due to indigestion, and was treated with family
remedies. In the afternoon the patient fainted, and by four o’clock
his pain had greatly increased in severity. He received a little morphine
and hot applications were applied. At 5 P.M. his mouth temperature
was 98.4°, his pulse too. During the night and the following day the
patient complained sometimes of severe pain, and occasionally felt
much better; he took a considerable quantity of milk, and at 8 P.M.
his temperature was only ioo°. During the second night he suffered
much pain, and at 5 A.M. on the 23d it was noted that his pain was
chiefly in the right iliac fossa. At 5.30 he had a severe chill and his
temperature rose to 103°, his pulse to 120. At this time he was visited
by his physicians. Dr. Fessenden N. Otis and Dr. William K. Otis,
who diagnosticated at once acute appendicitis, and requested me to
see the patient. This I did at about 8.30. I found the pulse and tem-
perature as stated, and the following condition: Great rigidity of right
abdominal muscles; exquisite tenderness on pressure at a point just two
inches internal to the anterior spine of the ilium, in the direction of the
umbilicus. Beneath the finger at this point could be felt a small
resisting mass, less than one inch in diameter. No dullness on percus-
sion anywhere. General appearance excellent. The diagnosis of
appendicitis already made by Dr. Otis was confirmed by myself, and an
hour later by Dr. Sands. Immediate operation advised and accepted.
General appearance of patient excellent. It should be noted that at
11.30 the temperature had fallen to ioi°.
Operation at 12 o’clock, just forty-nine hours from the first pain.
Present, Dr. F. N. Otis, Dr. William K. Otis, Dr. L. R. Morris, and
Dr. Tuttle.
Ether anesthesia. A slightly oblique incision four inches and a half
long, the center of this incision being two inches from the anterior iliac
spine toward the umbilicus. Tissues of abdominal wall quite markedly
edematous, particularly near the peritoneum. On opening the peri-
toneum freely, the appendix came at once into view. It was larger than
a man’s thumb, dark-brown in color, tense, evidently full of fluid, and
at no point gangrenous, but its wall evidently nearly as thin as paper.
A tail of omentum partly enveloped it, and this was much inflamed
and freshly adherent. Everywhere else the peritoneum was healthy,
and not an indication of the formation of any bounding wall of adhesions
existed. Coils of small intestine surrounded this full-to-bursting sac.
The omentum was gently separated and the inflamed portion ligated
and cut away. The mesentery of the appendix was carefully tied in
5 20 Medical Classics
sections, and the base of the appendix dislodged from an inverted pouch
of cecum, ligated at its base, and cut away. It proved to contain
at least half an ounce of very foul brown pus, but no concretion. Its
communication with the cecum was closed by stricture, so that the
unbroken, purulent, acutely inflamed cyst was removed entire. The
stump was disinfected with a i-to-iooo bichloride solution. Two
silver-wire sutures passing through the whole thickness of the abdominal
walls closed the upper part of the wound, and one similar suture the
lower part. The central portion was loosely packed with iodoform
gauze down to the ligated stump. Dressing of iodoform and bichloride
gauze over all.
At 6.40 P.M., less than six hours after the operation, patient’s
temperature was 99.8° and pulse 80. A small quantity of morphine
was given for wound pain. The dressings were changed on the third
day, and a perfectly aseptic condition of wound found. This patient
made a rapid and absolutely unbroken recovery, and is today per-
fectly well.
This is, I believe, the first recorded case where an acutely
inflamed unruptured appendix has been removed full of pus.
Who can doubt what the result would have been in this partic-
ular case had the cyst ruptured, and the operation been delayed
a few hours? Would not the opportunity for recovery have been
lost had the advice so often and so recently given been followed —
to delay operation until symptoms of spreading peritonitis
appeared?
Case II. — John S., ten years of age, was admitted to my care at the
Roosevelt Hospital on August 19, 1889. He gave no history of previous
attacks. A week ago he became ill, and complained of general ab-
dominal pain. He went to bed, and says that since that time he has
been feverish and has not been free from pain. Four days ago the chief
seat of pain is said to have been in the right side and low down. On
admission his pulse was no, his temperature 103.4 0 , and he was nau-
seated. Between the umbilicus and the right iliac spine was noted a
considerable tumor, which was markedly tender on pressure. The
percussion note over the tumor was dull. No tympanites existed. The
general appearance of the patient was that of severe illness. I operated
on the same day. The usual incision was made, and the tissues found
m a normal condition down to the peritoneum. The anterior peri-
McBurney’s Point 521
toneum itself was perfectly uninflamed, and uninflamed small intestine
covered the anterior face of the tumor. When these were drawn
toward the median (p, 68 1) line, a mass of adherent intestines were
disclosed, which inclosed a small indurated tumor.
The intestinal coils were gently separated on the anterior face of the
tumor, and several drachms of fecal pus at once escaped, emptying a
cavity somewhat tubular in shape and large enough to admit the finger.
The appendix lay in this cavity, congested, much swollen, and infil-
trated with pus. No perforation existed, and no concretions were
found. The appendix was tied off with silk and removed. A rubber
drain was introduced, the cavity packed with iodoform gauze beside the
drain, and a full antiseptic dressing applied.
On the following day, August 20th, the boy’s temperature was 99.6°
as against 103.4 0 the day before, a reduction in less than twenty-four
hours of nearly four degrees. This patient recovered rapidly and com-
pletely, and on September 2.5th his wound was entirely healed.
Case III. — W. K., a male, sixteen years of age, was admitted to my
care at the Roosevelt Hospital on July 26, 1889. Previous history
negative. Forty-eight hours before admission first felt pain in the
right iliac fossa. On the next day diarrhea set in; abdominal pain
was quite general, though more distinctly localized in the right iliac
fossa than elsewhere, and this increased up to the time of admission
to the hospital. The patient’s temperature was then 102°, his pulse
no. The abdomen was slightly distended and tympanitic. In the
-right iliac fossa was found a small, very tender non-fluctuating tumor,
which lay just inside of the anterior iliac spine. Diagnosis, acute
appendicitis.
Operation at 3.30, July 26th. The usual incision was made. Be-
neath the incision were found normal non-inflamed intestines. These
were drawn toward the median line, when the appendix was found
projecting stiffly forward and slightly upward by the inner side of the
caput coli.
It curled around the end of the cecum and then turned upward and
forward. Slight recent adhesions tied the appendix at its base only
to the cecum. At other points it floated freely among non-inflamed
intestines. The adhesions were broken down and the appendix ligated
at its base and removed. It was six inches and a quarter long, edema-
tous, and much thickened and inflamed throughout. Minute foci of
§22 Medical Classics
pus were scattered through its substance* but there was no concretion
and no perforation. On its removal the seat of operation was left
perfectly clean, but, to insure safety, a rubber drain was passed through
the loin directly to the base of the stump, and the anterior wound was
partly closed and partly packed with iodoform gauze. The next day
patient’s temperature was ioo°. His wound was inspected, but not
dressed completely until July 30th. No pus was found. The patient
made an unbroken recovery without incident, and his wounds were
completely healed on August 19th.
Case IV. — Annie O., eighteen years of age, was admitted to the
medical wards of the Roosevelt Hospital on May 2.9, 1888. Six years
ago she had an attack similar to the present one from which she entirely
recovered without operation. Two days ago she was seized with severe
epigastric pain accompanied by fever and headache, and tenderness on
pressure in the right iliac fossa. On admission, the abdomen was tense,
tympanitic, tender on pressure at all points, but more especially in the
right iliac fossa. Here a small tumor is distinctly felt. I saw this
patient for the first time on May 30th, and, having expressed the
opinion that she should be operated upon at once, she was transferred
to my care. At this time her symptoms had become much more threat-
ening; abdominal distension was extreme. Her temperature was low,
100.4°, pulse 100, respiration 36. I operated at once, making the usual
incision. The tissues of the abdominal wall were edematous and the
deeper ones much fused together. Beneath the center of the incision
the distal end of the appendix was readily found. It was much en-
larged and thickened, and greatly discolored. At first no pus was
seen, but, on gently separating the end of the appendix from adjacent
parts, a small cavity was found beneath it containing less than one
ounce of pus. The cavity was cleaned with hot water, and it was then
seen that the appendix was perforated at about its middle and lying in
the perforation was a large fecal concretion. The whole appendix was
then removed after ligating the base, the cavity was swabbed out
with i~ to- 1 .coo bichloride solution, two rubber drains introduced, and
the cavity packed with iodoform gauze. A complete antiseptic dressing
was applied. On June 1st the patient’s temperature was 99°, pulse
100, respiration 18. Abdomen free from pain or distension.
This patient made an unbroken recovery, being out of bed on June
23rd, with a small, superficial, flat ulcer still to heal.
McBurney’s Point 523
Case V. — Charles E. A., twenty-five years of age, was admitted to the
Roosevelt Hospital on September I, 1889. Patient gives a history of
probable appendicitis occurring five months ago.
Two days ago, after several weeks of abdominal discomfort, the
patient was seized with severe abdominal pain, nausea, vomiting,
and fever.
On admission, his temperature was 10*2°. Internal to the anterior
iliac spine, on the right side, some resistance and tenderness on pressure
were noted. Diagnosis, appendicitis.
On September ad, under ether narcosis, the usual incision was made,
the tissues of the abdominal wall being found very edematous. r Marked
adhesions and thickening of the peritoneum were found over a large
area, indicating clearly the existence at some previous time of a quite
extensive peritonitis. This probably occurred during the attack
referred to above. The appendix was found, after some difficulty,
hanging over the edge of the pelvis, greatly thickened and hardened.
After being freed from adhesions, it was ligated close to its base and
removed. The immediate neighborhood of the stump was cleansed
and the space packed with iodoform gauze. The upper portion of the
abdominal wound was closed by suture. With the exception that a
slight superficial abscess developed beneath the suture line, this patient
made an easy recovery, and was discharged, with a wound completely
healed, on October 17th. This patient was operated upon by Dr.
Frank Hartley, my first assistant at the hospital.
Case VI. — Miss E. C., twenty-five years of age, a patient of Dr. W. T.
Alexander, of this city, had complained of a sense of uneasiness and
discomfort in the right abdominal region, low down, for two or three
weeks. She had, however, gone about as usual, and walked several
miles daily. On June 18, 1889, in the evening, she was seized with
severe general abdominal pain, most severe in the epigastrium, and was
nauseated. She went to bed, and was then first seen by Dr. Alexander,
who diagnosticated appendicitis, and ordered hot applications and a
little morphine, with complete rest in bed. On the following day Dr.
Alexander asked me to visit the patient. This I did in the afternoon.
The patient’s temperature was then ioi °, and her pulse 100. She had
a very ill look, and complained bitterly of the slightest pressure over
the right iliac fossa and of some tenderness all over the abdomen. I
advised immediate operation. There were present at the operation
5 24 Medical Classics
Dr. W. T. Alexander, Dr. G. T. Jackson, and Dr. R. P. O’Neill, and these
gentlemen assisted me.
I made the usual incision. The tissues of the abdominal wall were
normal, and within the peritoneal cavity scarcely the slightest trace of
adhesions was found. The appendix, nearly completely gangrenous,
as large as one’s middle finger, lay just outside of the caput coli, not
perforated, but containing two large fecal concretions, just ready. to
escape through very soft (p. 682) gangrenous tissue. A little pumlent
fibrin lay beneath the appendix. No limiting wall of any kind existed,
and reddened small intestine lay above and below. The mesentery
of the appendix was carefully and with some difficulty tied off, the
appendix ligated at its base and removed. The immediate neighborhood
was then thoroughly cleansed with i-to-i,coo bichloride solution,
dusted with iodoform, and packed with gauze. A rubber drainage
tube was introduced beside the gauze down to the stump. The upper
part of the incision was closed with two sutures. The patient suffered
from nausea and tympanites for two or three days, when her tempera-
ture fell to normal and remained so. On the seventh day the wound
discharges were decidedly fecal, and continued to have this character
for about a week. The wound then became perfectly healthy and
rapidly healed. This patient has gained greatly in health and weight,
and has been, up to date, perfectly well.
Case Y 1 I. — Edgar C. B., a stalwart young man, twenty-one years
old, complained of pain in the lower part of the abdomen during the
evening of January 13, 1889. The next morning, when he had gone to
work, this pain spread through the whole abdominal cavity and became
very severe. He reached home with difficulty and went to bed. Dur-
ing the afternoon of the 14th— that is, at the end of about twenty-four
hours the pain localized itself chiefly in the right iliac and lumbar
regions. At noon on the 15th he had a chill, and, feeling very ill, came
to the Roosevelt Hospital in the evening. His temperature was then
101.6 , pulse and respiration about normal. The abdominal muscles
on the right abdominal half were rigid, and very acute tenderness was
complained of when pressure was made over the right iliac fossa about
two inches inside of the anterior iliac spine. No tumor could be felt.
The diagnosis of acute appendicitis was made, and I determined on an
immediate operation. This was done at 11 P.M., as nearly as possible
forty-eight hours after the first symptom. The usual incision was made.
The tissues of abdominal wall were found in a normal condition. Be-
McBurney’s Point 525
neath the line of incision were coils of non-inflamed small intestine.
These were pushed inward, exposing a mass of small intestines matted
together by adhesions and quite free from the iliac fascia. After a
short search, and after breaking down some of these adhesions, the
appendix was found, passing backward and inward from the cecum,
then doubling back upon itself. It was closely tied by adhesion to
the cecum and adjacent mesentery. The adhesions were broken down,
the mesentery of the appendix tied off in sections, and the appendix
itself ligated at its base with catgut and removed. The appendix was
much diseased, thickened, and distorted, but not ruptured. On section
I found within it some black, semi-fluid material. The mucous mem-
brane was gangrenous throughout, and the wall of the appendix at one
point gangrenous as far as the peritoneal coat. The stump was sponged
with i-to-i,ooo bichloride solution. The upper part of the wound
was closed with silver stitches, a rubber drainage-tube passed down
to the stump, and the open wound packed with iodoform gauze. Dur-
ing the next twenty-four hours considerable pain was experienced, and
for a few days constipation was obstinate. On the morning of the 17th,
the temperature became normal and remained so throughout con-
valescence, which was unbroken and entirely completed by February
nth. A small superficial ulcer was completely healed on February 21 $t.
Case VIII. — C. G. McK., a young gentleman twenty-three years
old. First attack of pain in right iliac fossa two years ago. Second
attack in May last, when he was confined to bed five days with fever
and severe pain and tenderness in the same region. On Thursday
morning, October 17th, he had a sudden attack of severe pain in region
of appendix, went to bed, and his temperature was noted to be 99 0 .
In the evening his temperature rose to icx}°. Pain and tenderness
steadily increased. Friday he remained in the same condition, and
was seen by me, at the request of Dr. E. E. Swift, later at night. The
patient was haggard and looked ill. Tenderness on pressure about two
inches inside of the iliac spine was very marked. An ill-defined tumor
existed, and decided distension of the abdomen. Operation was
advised, but the circumstances were such that it was postponed until
twelve o’clock on the following day.
Operation October 19, 1889. Ether anesthesia. The usual incision
was made. On opening the peritoneum, an enormously distended caput
coli filled the wound and rendered the search for the appendix extremely
difficult, forcing me to handle the intestines far more than was to be
526 Medical Classics
desired. The appendix was at last found, flat, wide, and so firmly
adherent to the under surface of the cecum as to be identified with
great difficulty, and numerous firm old adhesions prevented the free
movement of intestines and at one point formed a nearly constricting
band. An indurated mass beneath the center of the appendix was
opened with the finger by separating adhesions which, however, were
very strong, and many of them evidently old. From this mass about a
drachm of foul fecal pus escaped and was sponged away. The difficulty
of dissecting away the appendix was so great that I was finally obliged
to desist and to be satisfied with removing only that portion of it
which formed the wall of the abscess. The cavity was very thoroughly
cleansed, and an attempt made to return the prolapsed large intestine
and close the wound. This was found to be exceedingly difficult, owing
to the very excessive distension of the gut, and much time was expended
and much handling of gut necessitated. Finally the wound was closed
as in other cases, the lower part being packed and drained. The patient
recovered well from the effects of the operation, but at the end of twen-
ty-four hours his temperature rose to 102°, and the abdominal distension
increased. He was bright and looked fairly well, however, and I did
not expect serious illness. His temperature, however, continued to
rise, symptoms of peritonitis developed, complete paresis of bowel
persisted, and the patient died at the end of four days, of peritonitis.
No autopsy could be obtained.
Whether the difficult and unusual handling of the intestines
was the chief cause of peritonitis, or whether constricting bands,
formed by old adhesions, caused actual obstruction, I am unable
to say. No movement of the bowels could be obtained and
no flatus passed after the operation excepting by the aid of a
long rectal tube. Certainly the peritonitis was not septic, and
such was the opinion of Dr. Delafield and Dr. Swift, who visited
the patient with me. Moreover, when, on the second day, I
removed the packing, I found a perfectly healthy wound, without
the slightest sign of infection. One thing is clear— -that, had
the operation been done during the patient’s first attack two
years ago, none of the great difficulties which I met with would
have been encountered.
I stated at the beginning of this paper that I did not here intend
to review the treatment of appendicitis in a systematic manner,
McBurney’s Point 527
but I should not do justice to the real subject of this writing were
I to drop the matter at this point. I must, in the first place, as
accurately as possible, define the class of appendicitis to which
I have applied the method of treatment described; and then
I wish to devote a few minutes to a description of the technique
of the operations. I have presented eight cases of appendicitis
operated upon at an early state of acute inflammatory process.
These eight cases include all of those (p. 683) operated upon
since May 20, 1888, to date. Previous to May ao, 1888, I had
never operated upon a case except by the older methods. During
this period of eighteen months I have seen and operated upon
a much larger number of cases of appendicitis at late stages in
the disease — that is, when extensive abscess has existed, and in
some cases of early general septic peritonitis due to appendicitis.
Such cases are excluded from the list given, as belonging to an
entirely different category. I have measured the stage of the
disease, not by the number of hours or even days that it has
existed, but by the character and extent of the inflammatory
process, all cases being included in the list excepting those where
it was clear that large, comparatively safe abscess was forming,
or where general septic peritonitis was already established. I
should, moreover, state that in every case operation has been done
as soon as possible after being seen, excepting that in the fatal
case various circumstances, contrary to my wish, necessitated
a delay of about twelve hours. In no case has a diagnosis of
appendicitis been made which has been subsequently proved by
operation to be incorrect. To those who have been in doubt as
to whether the operation or the disease carries with it the most
danger, I think these cases, although limited in number, must
be convincing in favor of the operation. All will acknowledge
that every case of appendicitis may, so far as the cleverest
observer can tell, have to pass by many very dangerous obstacles
before reaching the smooth water of a confortable abscess. For
my part, I would endeavor to insure safety early, before reaching
the rapids, rather than trust to finding my way with my eyes
blindfolded through a dangerous passage. I am familiar with
the good-natured jest that the surgeon is now ready to cut every
^ 2 8 Medical Classics
one who has a stomach-ache. The death-rate from appendicitis
within the professional circle of New York alone is a sufficient
answer to that criticism. _ _
How I should be much misunderstood if I should give the
impression that, while I believe the operation to be less dangerous
than the disease, I also believe the operation to be simple and
easy of execution. I look upon it as often an exceedingly difficult
one, and one which requires as much care and patience and
attention to detail as any with which I am familiar. Moreover,
I have never seen two cases of appendicitis operated upon in
which the pathological conditions, the position of adhesions, the
relation of surrounding parts, etc., were very nearly alike. Every
case presents some new problem, and in every case there is
large opportunity for the exercise of careful judgement as to how
best to meet this or that difficulty. Of course there must be
pioneers, as Sands was, and such may be the most successful,
but my strong feeling is that it is well worth while for any one who
may have to do this operation to see it done, at least once, first.
Before describing the steps of the operation, I refer again to
the important aid to diagnosis of which I have already spoken —
namely, the ascertaining, by the pressure of a single finger-tip,
that the point of greatest tenderness is, in the average adult,
almost exactly two inches from the anterior iliac spine, on a line
drawn from this process through the umbilicus. Much greater
tenderness at this point than at others, taken in connection with
the history of the case and the well-known signs, I look upon as
almost pathognomonic of appendicitis. This point indicated
the situation of the base of the appendix, where it arises from
the cecum, but does not by any means demonstrate, as one
might conclude, that the chief point of disease is there. The
abscess, or concretion, or cyst may be at quite a little distance,
but the greatest pain, on pressure with one finger, will be felt
at the point described.
The incision should be a liberal one, for much room may be
r ?T J ed r’,f nd a five - inch cut in the adult is not too much. It
should follow as nearly as possible the right edge of the rectus
muscle, and the center of the incision should lie opposite to or
McBurney’s Point 529
a little below the anterior iliac spine, on a line drawn to the
umbilicus. When the external oblique aponeurosis is cut through
by this incision, the aponeurotic structure, in which the other
abdominal muscles end, comes into view, and is easily divided
without cutting muscular fiber. Then the fascia transversalis,
the subperitoneal fat, and the peritoneum are cut in succession.
If pus has formed close against the anterior abdominal wall,
these last-mentioned tissues will be found infiltrated with serum,
or even thickened so as to look like cheesy tubercle. Otherwise
these parts may appear perfectly normal. On opening the
peritoneum the appendix may at once be seen, or adhesions and
inflammatory exudations may have so distorted the parts that
a careful and difficult search may be required to find the appendix
at all. It may be flattened out and glued firmly to the inflamed
surface of the cecum by old and recent adhesions, or it may be
coiled upon itself and buried out of view in a mass of lymph.
The finger is often quicker than the eye to detect the appendix
in these conditions, as it is very certain to be found where the
greatest thickening, as felt by the finger, exists. More than
once I have had to turn the cecum out of the wound and ex-
amine carefully the usual region of origin of the appendix before
I could identify it. Usually then with the finger or a dull-pointed
instrument the adhesions can be broken down or tied off, as
may seem required by vascularity. If the appendix has been
thus separated, I have usually tied it off with silk or catgut close
to the cecum and cut it away, and generally between two liga-
tures. Careful disinfection of the stump should be made. I
have scraped its interior and disinfected with i-to-i,ooo bichloride
solution, and then rubbed in iodoform. Once, when it looked
dangerous, I tied with selver wire, and then used the fine-pointed
cautery to disinfect. If thoroughly cleansed, it seems to be
unnecessary to lose time in sewing the peritoneum over the
stump, as recommended by Treves. When the appendix has
been removed nothing remains to be done but to disinfect the
whole neighborhood, insert a drain, and pack the small space
with iodoform gauze. The upper half of the wound may per-
fectly well be tightly closed with stout sutures, which should
^ ^ o Medical Classics
include the whole thickness of the abdominal wall— peritoneum
as well. In some cases I believe it to be good practice to intro-
duce a large drain by a separate opening well above and behind
the iliac spine, for in some cases the region of disease may extend
especially in that direction (p. 684). But the question may
fairly arise in any case as to whether it is wise to attempt to
dissect out the appendix and remove it. If the difficulties of
dissection would evidently be very great, I think it is better to
open the abscess if there is one, cleanse the cavity, and, leaving
the appendix in situ , pack and drain the wound.* The packing
I have usually removed on the third day and replaced it with
less, and the cavity has rapidly granulated. If, at the time of
operation, one introduces sutures throughout the whole length
of the wound, leaving the central and lower ones loose, these
can subsequently, after one or two dressings, be tied, and the
wound thus rapidly narrowed. Over the whole wound, of course,
a complete dressing is applied, and good bandaging is better
than any binder, to prevent the possibility of extrusion of gut
by ether vomiting or intestinal distension. None of my patients
have developed a hernia at the site of operation. I have kept
them all in bed for four weeks or more. None have had any
recurrence of inflammatory action of any kind.
A few more words, Mr. President, and I have finished. Are
there any contra-indications to this operation in a clear case of
appendicitis? I think there are. Very great abdominal dis-
tension, tvhich might be in a given case probably be relieved
by a few hours treatment, would lead me to delay the operation,
for expulsion of intestine is a very serious obstacle to the proper
completion of the operation without risk. Unusual obesity I
should regard as a good reason for a more expectant method
of treatment. But the most important contra-indication of all
is the absence of any one of the necessary safeguards and aids,
such as the best assistance, the best light, and the best appliances
for performing a perfectly aseptic operation.
operated upon since writing this paper, it would have been a dangerous
Sa^e^nr 0 T K f^^ted and strongly adherent appendix. I broke its
F i“ Tl ° Ugh the l0b and packed in front * The treatment
w^ completely successful, and the patient is safely convalescent.
McBurney’s Point 531
Note. — Since writing the foregoing paper, I have operated in
three other cases of acute appendicitis. One of them was that
of a lad, fifteen years old, a patient of Dr. G. A. Spaulding’s.
The operation was done at the fortieth hour of the disease, the
temperature being high and the symptoms very threatening.
The appendix, much diseased and containing two large concre-
tions, was removed. The temperature fell on the following day
to 99 0 , and has been normal ever since that time. The patient
is now safely convalescent.
The second case was that of a patient of Dr. Jarecky’s, fifteen
years old. The operation was done at the beginning of the fifth
day. The appendix, gangrenous at two points as far as the
peritoneal coat, was still not perforated even at this late date.
It was removed, and the patient is now safely convalescent.
The third patient, already referred to in a note, is nearly well.
None others have been operated on in an acute state of inflam-
mation up to date. The number of operations is, therefore,
eleven. Of these, one proved fatal, probably from obstruction
by a band not discovered.
THE END
McBURNEY’S INCISION
While professor of clinical surgery at the College of Physicians
and Surgeons in New lork City, in 1894, at the age of 49, Dr.
Charles McBurney proposed a new incision for appendectomy
which still bears his name. He then had had charge of the
entire suntical service of Roosevelt Hospital for six years, so that
his sureical knowledge and judgment must have been founded on
at least hundreds of cases. McBurney recommended this new,
muscle-splitting or gridiron incision because its use gave a more
direct approach to the appendix and reduced the incidence of post-
operative incisional hernia. The objections which he listed were
(1) a too limited exposure of the abdominal cavity, (2) insufficient
room for extensive drainage and (3) the need of two extra assist-
ants to hold retractors. McBurney described a method of enlarg-
ing the incision when necessary by continuing the original muscle
splitting. He had used the incision in only four cases when he
wrote this paper. See following pages for complete article.
Today, 40 years later, the McBurney incision is probably more
extensively used for appendectomy than any other. When
complete exploration of the abdominal cavity is desired, other
incisions (paramedian) are recommended; one of these was
originally used by McBurney. Adequate drainage is obtained
through this incision by employing rubber tubes or cigarette
(gutta-percha and viaform gauze) drains. At the present time
the entire abdominal opening is held apart by one pair of retrac-
tors, not by four as described by the originator. A further
objection that has been given is the liability to right inguinal
hernia some time after the operation, caused bv injury to the
iliohvpogastric and ilioinguinal nerves by incision or retractor.
The incidence in D. C. Balfour’s series (Railway Surg. lour., 19:
117-119, 1912 and Mayo Clinic Papers, 4: 242-245, 1912) in
which, out of 79 5 patients operated on for right inguinal hernia,
ty had had a previous appendectomy through a McBurney in-
cision, seems small enough to be coincidental. Even these objec-
tions can be answered by recommending enlargement of the
incision upva* j rather than downward, minimal injurv to tissues
b\ retractors and use of soft, flexible drainage wicks.
The solution to the whole controversy lies in the fact that the
Md urnev is an efficient incision in properly selected cases and
ill a o[. SUrge< ? n f hould , be P re Pared to use any known method
that w ill be to the best advantage of his patient.
The Incision Made in the Ab-
dominal Wall in Cases of Ap-
pendicitis, with a Description
of a New Method of Operating
BY
CHARLES McBURNEY, M.D.
Surgeon to the Roosevelt Hospital \ New York
Published in The Annals of Surgery, 20: 38-43, 1894
(J. B. Lippincott Co., Philadelphia, Pa.)
URGEONS are practically unanimous in dis-
carding the median incision of the abdominal
•wall when operating for appendicitis. The
division of the tissues in the median line is
very easily accomplished, and the repair of the
wound is probably more perfect than when the
incision has been made at any other point, but the entrance to
the peritoneal cavity, which is thus affected, does not so readily
permit the operative work in connection with the appendix
within the cavity, or the subsequent treatment of the wound in
any case where complete closure of the incision is contraindicated.
The usual situation of the appendix, well to the right of the
edge of the rectus muscle, and the fact that abscesses and other
lesions arising in disease of the appendix are largely confined
to the right half of the abdomen, have led operators, almost
without exception, to make their entering incisions either at the
a Medical Classics
outer edge of the rectus or at some point between this muscle
and the anterior spine of the ilium.
In my earlier operations for the removal of the appendix at
the beginning of the disease, and in recurrent cases operated
upon in the interval between attacks, I always made the incision
parallel with and near the right edge of the rectus. The advan-
tages of this incision are that the deeper tissues divided are
purely tendinous, that the hemorrhage is slight, and that the
suture of the wound, when closure is permitted, is very easy and
satisfactory (p. 39). The disadvantage is that the situation of
the appendix is usually still farther to the right; indeed, it is
often close to the outer part of Poupart’s ligament, and, fre-
quently enough, the appendix points upward to the outer side
of the colon. In ail such cases, if an incision by the side of the
rectus is made, the operator is forced to v'ork beneath the over-
hanging shelf formed by the outer part of the abdominal wall,
and the subsequent removal and reintroduction of gauze drainage
material, in cases where complete closure is contraindicated, is
decidedly interfered with. It has seemed to me that in all cases
wdiere it is desirable first to locate the base of the appendix, and
. usually too where one wishes to make an entrance into an abscess
originating in disease of this organ, it is much better to incise
the abdominal wall a little to the outer side of the normal situa-
tion of the appendix. The inner edge of this wound is drav'n
inward by a retraction, and but little tissue has to be drawn
outward in order to fully expose the caput coli and allow of easy
indentification of the base of the appendix. Through this
incision also, or through a parallel one made still nearer to the
anterior spine of the ilium, it is easy to enter, empty, and sub-
sequently treat almost every case of abscess. Of late years I
have made almost all incisions for appendicitis about as follows:
The incision in the skin is an oblique one about four inches long.
It crosses a line drawn from the anterior iliac spine to the um-
bilicus nearly at right angles about one inch from the iliac spine,
and is so situated that its upper third lies above that line.
The incision of the aponeurosis of the external oblique is a
little shorter, and practically merely separates the fibers of that
McBurney’s Incision 535
muscle and its tendon without cutting them. The section of
the internal oblique and transversalis muscles follows, cutting
the muscular fibers nearly at right angles to their course, and is
completed only at the central half at first. This deeper incision
can be readily lengthened if, after cutting the fascia transversalis
and peritoneum, the character of the lesion seems to call for
more space. The above description corresponds accurately to
the incisions I have made during the last few years in the large
majority of cases, although, of course, abscesses unusually placed
(p. 40) have required sometimes a larger opening, and sometimes
an incision beginning at a higher or at a lower point, or placed
much nearer Poupart’s ligament. In all of these sections the
damage done to the abdominal wall is considerable, and we have
all of us been disappointed, especially after operating upon
supprating cases, when it has been necessary to treat abscess
cavities with gauze drainage, to find that even very perfect
treating of the wound has been followed by small or large ven-
tral herniae.
It can certainly be affirmed that the formation of a hernia
subsequent to these operations is not due to any particular
length of incision, nor can a specially restricted incision insure
against the same result.
In regard to the exact length of the incision, I would say that
it should be adjusted to the necessities of the case, just as in-
cisions in other parts of the body, made for various purposes,
should be adjusted. Incisions should be long enough to allow
complete and safe work to be done, and it is most unscientific
and harmful to encourage those of limited experience to believe
that a special measure of good goes with a special length of
incision. If the parts severed in the making of a wound are
properly adjusted, and the wound properly treated, repair will
be just as rapid and complete whether the wound be five inches
long or three inches long, while, on the -other hand, no good
surgeon will ever unnecessarily divide tissue simply because he
can again obtain repair.
When hernia occurs after an operation for appendicitis, it
is due to the imperfect repair following the complete section of
Medical Classics
a number of superimposed tissues, and it has sometimes followed,
both in cases where the incision was made just at the linea semi-
lunaris, and also when made through the muscular wall outside
of this line. In abscess cases where a free incision and also open
treatment of the wound for drainage are essential to safety,
hernia of greater or less dimensions is not unfrecjuently seen
without a year after operation.
By the term hernia, used in this connection, is meant the
partial eversion of the cicatrical tissue caused by intra-abdominal
pressure at one or more points in the line of the wound, where
(p. 41) repair of the deeper tissues incised has been imperfect.
Even after operations for the removal of the appendix in the
interval between attacks, and when the wound may be completely
or nearly completely closed at once, small herniae, of the same
variety, are not unknown. The recurrence of hernia is due,
first, to the more or less constant intra-abdominal pressure, and
secondarily, to the difficulty in obtaining perfect repair in the
parts divided. The peritoneum is often very perfectly sutured,
the transversalis fascia usually very imperfectly. The external
oblique aponeurosis is usually, when its suture is permissible at
all, very completely repaired. The greatest defect in repair is
due to the section at right angles either of the muscular fibers
of the internal oblique and transversalis, or of the tendinous
fibers forming the conjoined tendon of these muscles at the
edge of the rectus. In either case, the retraction of these mus-
cular fibers, aided by intra-abdominal pressure, tends constantly
to separate the edge of the deeper part of the wound, thus per-
mitting at first slight, afterwards increasing, eversion of the
peritoneum, and the formation of an incomplete hernial pouch.
Such cases require the use of an abdominal belt or other apparatus
to give sufficient support to the belly wall. The consideration
of this defective result in some cases has led me to attempt a
different method of entering the cavity in operations for the
removal of the appendix in non-suppurative cases.
The skin incision should be made as already described. The
sect'on of the external oblique muscle and aponeurosis should
orrespond, great care being taken to separate these tissues in
McBurney’s Incision 537
the same line, not cutting any fibers across. This is easily ac-
complished.
When the edges of the wound in the external oblique are now
strongly pulled apart with retractors, a considerable expanse of
the internal oblique muscle is seen, the fibers of which cross
somewhat obliquely the opening formed by these retractors.
With a blunt instrument, such as the handle of a knife or closed
scissors, the fibers of the internal oblique and transversalis
muscles can now be separated, without cutting more than an
occasional fiber, in a line parallel with their course, — that is,
nearly (p. 42) at right angles to the incision in the external
oblique aponeurosis. Blunt retractors should now be introduced
into this in turn and the edges separated.
The transversalis fascia is thus well exposed and is then divided
in the same line. Last of all the section of the peritoneum
is made.
Two sets of retractors must be in use, one holding open the
superficial wound from side to side, the other separating the edges
of the deeper wound from above downward. A considerable
opening is thus formed, through which, in suitable cases, the
caput coli can be easily handled, and the appendix removed.
The appendix having been taken away, the wound in the peri-
toneum, which is transverse, is then closed by suture. The
similar wound in the fascia transversalis is also sutured. The
fibers of the internal oblique and transversalis muscles fall to-
gether as soon as the retractors are withdrawn, and with a couple
of fine catgut stitches the closure can be made more complete.
The wound in the external oblique aponeurosis is sewed with
catgut from end to end. When the operation is completed it
will be seen that the gridiron-like arrangement of the muscular
and tendinous fibers, to which the abdominal wall largely owes
its strength, is restored almost as completely as if no operation
had been done. In performing this operation I have noticed
several advantages.
In the first place, muscular and tendinous fibers are separated,
but not divided, so that muscular action cannot tend to draw
the edges of the wound apart, but rather to actively approximate
538 Medical Classics
them. Excepting during the incision of the skin, almost no
bleeding occurs. The fascia transversalis not being drawn away
by the retraction of the deepest layer of muscular fibers, thi'
fascia is easily completely sutured, and thus greater strength
of repair is assured. No muscular fibers or larger nerves having
been divided, pain after operation is almost absent. The opera-
tion requires rather more time than the usual one, and a larger
number of assistants is needed, for four retractors are in use
during part of the time. The opening into the peritoneal cavity
is not large, but may be made larger if necessary, by continuing
(p. 43) the separation of the fibers of the internal oblique and
transversalis, and dividing the conjoined aponeurosis in the
same line with scissors. In the opposite direction the sepa-
ration of muscular fibers may be carried out as far as the crest
of the ilium.
I have now done this operation on four patients, all cases of
recurrent appendicitis operated upon in the interval between
attacks. The first operation took place at the Roosevelt Hospital
on Dec. 18, 1893. Sufficient time has not elapsed to justify
me in presenting the final results as positively an improvement
upon those obtained by older methods. I shall expect, however,
in these cases, a much more perfect result as regards the strength
of the abdominal wall than is usually observed.
I present the method now, hoping that others may be induced
to give it a trial.
This operation does not appear to be suitable for cases accom-
panied by suppuration about the appendix, which require to be
treated by extensive packing with gauze, nor in cases non-sup-
puratiye which require during operation a large intra-abdominal
dissection.
It is not an easy operation, and should not be attempted by
those who are unfamiliar with operations upon the appendix,
and I again call attention to the fact that in performing it two
extra assistants will be occupied part of the time with retractors.
THE END
MEDICAL CLASSICS
VOL. II
February, 1938
NO. 6
CONTENTS
Portrait of Carlos Juan Finlay - -- -- -- - 540
Carlos Juan Finlay
Biography ------------ - 541
Bibliography of Writings - -- -- -- - 543
Index to Bibliography - -- -- -- -- 564
El Mosquito Hipoteticamente Considerado como Agente
de Trasmision de la Fiebre Amarilla, Dr. Carlos
J. Finlay - -- -- -- -- -- -- 569
The Mosquito Hypothetically Considered as the Agent
of Transmission of Yellow Fever. Dr. Carlos J.
Finlay - -- -- -- -- -- -- - 590
Yellow Fever: Its Transmission by Means of the Culex
Mosquito. Charles Finlay, M.D. - - - - - 613
Inoculations for Yellow Fever by Means of Contaminated
Mosquitoes. Charles Finlay, M.D.- - - - - 634
MEDICAL CLASSICS
vol. ii February, 1938 no. 6
Carlos Juan Finlay
BIOGRAPHY
1833 Born December 3, in the city of Puerto Principe (now
Camagiiey), Cuba. His father, Edward, was a Scottish
physician and his mother, Isabel de Barres, was a native
of France. Christened Juan Carlos, used Carlos as
name, added J. as middle initial when his son, Carlos E.,
began practice of medicine. Family early moved to
Havana and Guanimar where Edward Finlay had a
coffee plantation.
1 844 Age 1 1 . Sent to France and entered a school at the Havre.
1846 Age 13. Returned to Cuba because of an attack of chorea
which “left him with a serious stoppage in his speech
which was cured after a careful course of training in-
stituted by his father.”
1848 Age 15. Returned to Europe. Because of revolutionary
movements in France, studied in London for a time and
then in Mentz on the Rhine for one year. Attended
college in Rouen.
1851 Age 18. Returned to Cuba to convales'ce from typhoid
fever.
1855 Age 11 . Graduated from the Jefferson Medical College
of Philadelphia where his most influential teacher was
Dr. John Kearsly Mitchell, an early worker in the germ
theory of disease, and whose son, Dr. S. Weir Mitchell,
was his private preceptor.
1856 Age 23. Practiced medicine for a short time with his
father in Lima, Peru.
541
Medical Classics
1857 Age 24. Incorporated his diploma in the University of
Havana and began practice of medicine.
i860 Age 27. Visited Paris, attended hospital clinics.
1864 Age 31. Started a practice in Matanzas, near Havana,
with general medicine and ophthalmic surgery.
1865 Age 32. Married in Havana, Miss Adela Shine, a native
of the Island of Trinidad. “They have founded a family
much esteemed in the social circles of Havana.” One
of his three sons is Carlos E. Finlay, M.D., F.A.C.S., a
practicing physician in Havana.
1869 Age 36. Visited for several months in Trinidad.
1875 Age 42. Visited New York seeking medical aid for his
wife.
1881 Age 48. First made public his views on the transmission
of yellow fever by an intermediary agent at the Inter-
national Sanitary Conference in Washington.
1898 Age 65. Became United States Army surgeon in Spanish-
American War. Worked at Santiago.
1901 Age 68. Received Mary Kingsley medal from the Liver-
pool School of Tropical Medicine.
1902 Age 69. Appointed Chief Health Officer and President
of the Superior Board of Health by the Cuban Govern-
ment.
1 9°5 Age 72. President of the 32nd session of the American
Public Health Association held in Havana.
1908 Age 75. Made an officer of the Legion of Honor by the
French Government.
Retired because of age from office of Chief of Sanitation.
1909 Age 76. Appointed Honorary President of the National
Board of Sanitation and Charities at a salary of $2 } $oo.oo
a year.
I 9 11 Age /8. Elected a Corresponding Member of the French
Academy of Medicine.
I 9 I 5 Age 82. Died on August 20 in Havana.
Received LL.D. from Jefferson Medical College.
Honorary Fellow of the College of Physicians of Phil-
adelphia.
Carlos Juan Finlay 543
Member of the Academy of Medical, Natural, and Physi-
cal Sciences of Havana.
Member of the “Sociedad de Estudios Clinicos.”
BIBLIOGRAPHY OF WRITINGS
ABBREVIATIONS
A. de la A. (Anales de la Real Academia de Ciencias Medicas.
Fisicas y Naturales de la Habana, y Anales de la Academia
de Ciencias Medicas, Fisicas y Naturales de la Habana).
Arch, de' Med. Nav. (Archives de medecine navale).
Arch, de la S. de E. C. de la H. (Archivos de la Sociedad de
Estudios Clinicos de la Habana).
Bol. de las D. ocurr. en el T. M. de la H. (Boletin de las Defun-
ciones ocurridas en el Termino municipal de la Habana).
C. M-Q. de la H. (Cronica Medico-Quirurgica de la Habana).
Gac. M. de la H. (Gaceta Medica de la Habana).
Jour. Amer. Med. Assoc. (The Journal of the American Medical
Association).
La Enc. (La Enciclopedia).
Prog. Med. (El Progreso Medico).
Rev. de C. M. (Revista de Ciencias Medicas).
Rev. de M. y C. de la H. (Revista de Medicina y Cirugia de la
Habana).
Rev. Med. Cub. (Revista Medica Cubana).
Rev. de M. Trop. (Revista de Medicina Tropical).
Rev. de la A. M-F. de la I. de C. (Revista de la Asociacion Me-
dico-Farmaceutica de la Isla de Cuba).
Trab. de la Com. de M. L. e H. P. etc. (Trabajos de la Comision
de Medicina Legal e Higiene Publica de la Academia de
Ciencias Medicas, Fisicas y Naturales de la Habana, etc.).
1. Bocio exoftalmico. Observacion. (Exophthalmic goitre.
Observation.) A. de la A. i: 21-27, 1864.
2. El colera y su tratamiento. (Cholera and its treatment.)
Ibid., 2: 375-383, 1865.
3. Hernia mguino-escrotal oblicua. Estrangulacion durante
41 horas. Vdmitos estercoraceos. Curacion. (Oblique
544 -
Medical Classics
ingumal-scrotal hernia. Strangulation for forty-one
hours. Fecal vomiting. Cure.) Ibid., 3* 4 3 i— 4^6,
1866.
4.. Carta remitida al “Diario de la Marina sobre el colera en
el Cerro. (Letter sent to the “Diario de la Marina” on
cholera in Cerro.) Written June 27, 1868. Appears
first time in Trabajos selectos del Dr. Carlos J. Finlay,
Habana, pp. 575—578, 1912 .
5. Alcalinidad atmosferica observada en la Habana. (Alka-
linity of the atmosphere observed in Havana.) A. de la
A. 9: 183-192, 187a; 10: 42-46, 1873.
6. Discusion del informe del Sr. Melero relativo a la explosion
de una retorta en que se preparaba oxigeno. (Discussion
of the report of Mr. Melero on the explosion of a retort
in -which oxygen was prepared.) Ibid., 9: 413, 1872.
7. Transmision del colera por medio de las aguas corrientes
cargadas de principios especificos. (Transmission of
cholera by means of running water charged with the spe-
cific principle.) Ibid., 10: 159-170, 1873.
8. Casos de tetanos tratados por el hidrato de cloral. (Case of
tetanus treated by chloral hydrate.) Ibid., 10: 238,
l8 ? 3 '
9. Explicacion del cuadro de casos de colera observados en el
Cerro desde Noviembre 11, 1867, hasta Enero 29 de 1868.
(Explanation of a list of cases of cholera observed at
Cerro from Nov. n, 1867 to Jan. 29, 1868.) Ibid., 11:
70-75, 1874.
10. Consideraciones relativas a una observacion interesante de
cancer y su tratamiento quirurgico. (Considerations
relative to an important observation on cancer and its
^ surgical treatment.) Ibid., ii: 357-361, 1874.
11. Nueva teoria de la gravitacion. (New theory of gravita-
tion.) Ibid., ii: 429-441, 1874.
12. Nota adicional a la “Nueva teoria de la gravitacion.”
(Additional note on the “New theory of gravitation.”)
Ibid., 11 : 469-475, 1874.
Carlos Juan Finlay 545
13. Segundo informe relativo a la misma fabrica de jabon.
(Second report on the manufacture of soap.) Trab. de
la Com. de M. L. e H. P. etc., 3: 332-338, 1874. Also:
A. de la A., 16: 286-288, 1874.
14. Informe sobre el pliego de condiciones a que ha de ajus-
tarse la nueva empresa del alumbrado de gas de la Habana.
(Report on the specifications for regulating the new enter-
prise of gas-lighting in Havana.) Trab. de la Com. de
M. L. e H. P. etc., 3: 344-349, 1874. Also: A. de la A.,
15: 165-166, 1878.
15. Informe acerca de la memoria “Aclimatacion e Higiene de
los Europeos en Cuba.” (Report on the account “Accli-
mation and hygiene of Europeans in Cuba.”) A. de la A.,
12: 66-84, 1875.
16. Consideraciones generales sobre la extraccion de los cataratas
y descripcion de un nuevo metodo operatorio. (General
considerations on the extractions of cataracts and de-
scription of a new operative method.) Ibid., 12: 285-
298, 1875.
17. Observaciones de una extraccion de catarata por su nuevo
metodo operatorio y de una catarata congenita. (Obser-
vations on the extraction of cataract by a new operative
method and of congenital cataract.) Ibid., 12: 339-342,
1875.
18. Informe sobre des obras de oftalmologla. (Report on some
works on ophthalmology.) Ibid., 12: 427-435, 1875.
19. La verdad cientifica, la invencion y su correctivo. (Scien-
tific truthfulness, invention and accuracy.) Ibid., 13:
36-44, 1876..
20. Datos relativos a la corea: investigacion. (Data relative
to chorea: investigation.) Ibid., 13: 247-248, 1876.
21. Patologia y terapeutica del oparato lenticular del ojo por
el professor Otto Becker de Heidelberg. (Pathology and
treatment of the lenticular apparatus of the eye by Pro-
fessor Otto Becker of Heidelberg.) Translation by Fin-
lay from the German. 432 pp., 4 0 , Habana, G. Montial
y Ca., 1876.
54 $
Medical Classics
22. Oftalmologia. Inconvenientes de la atropina. (Ophthal-
mology. Disadvantage of atropine.) A. de la A., 13:
495-504, 1 876. ^ , J ,
23. Critica de la Memoria del Dr. Santos Fernandez acerca de
los “Trastornos del aparato de la vision en las fiebres
paludicas y accidentes a que puede dar lugar su ineludible
tratamiento por el sulfato de quinina.” (Criticism of the
account of Dr. Santos Fernandez on the “Disturbances of
visual apparatus in malaria and the accidents which may
supervene in the unavoidable treatment with quinine.)
Ibid., 14: 454-464; 5 ° 9 ~ 5 1 3 , i8 77 -
24. Informe sobre el Reglamento de la Sociedad Antropologica
de la Isle de Cuba. (Report on the by-laws of the An-
thropological Society of the island of Cuba.) Ibid., 14:
57 2 , l877>
25. Mocion del Dr. Finlay referente a los academicos penodistas.
(Plan of Dr. Finlay in reference to the Academy of Jour-
nalists.) Ibid., 15: 179-182, 1878.
26. Clima de la isla de Cuba. (Higiene publica.) (Climate of
Cuba. (Public Hygiene.)) Ibid., 15: 261-273, 1878.
27. Apologia del clima de Cuba. (Apology of the climate of
Cuba.) Gaz. M. de la H., 1: 1-3, 1878. Also: Rev. de
med. y drug, pract., Madrid, 3: 496-500, 1879.
28. Utilidad de los ejercicios comporales en los climas calidos,
y su conveniencia para formentar el desarrolo fisico de
nuestra juventud. (Benefit of physical exercises in a
warm climate and their advantages in the development of
the physique of our young people.) Gac. M. de la H.,
1: 116-117; 135-137, 1879.
29. Memoria sobre la etiolog'ia de la fiebre amarilla. (Account
of the etiology of yellow fever.) Ibid., I: 161-165; 177—
™ 7 ~ 9 ; 20 ~ 2 3 , 1879; 33 - 35 ; 53 - 59 , 1880.
3 • en um. ^ Report of the alkalinity of the atmosphere
observed in Havana and other localities of the island of
Cuba. . (Portion of report of the Havana Yellow Fever
Commission. Spanish Commission.) Supplement Nat.
Board of Health Bull, Washington, pp. 18-19, 1879.
Carlos Juan Finlay 547
Also, in Spanish: C. M-Q. de la H. 6: 375-380, 1880.
Also, in Spanish: Gac. M. de la H., 2: 158-160, 1880.
31. Informe acerca de un vendaje compresor binocular. (Re-
port on a binocular compression bandage.) A. de la A.,
16: 70, 1879.
32. Discusion sobre el tratamiento electroterapico del bocio
exoftalmico. (Discussion of the electrotherapeutic treat-
ment of exophthalmic goitre.) Ibid., 279-280, 1879.
33. Discusion del “Informe sobre secuestracion de los lazarinos”
del Dr. Nunez. (Discussion on “The report on the segre-
gation of lepers” by Dr. Nunez.) Ibid., 16: 297-301,
i 8 79-
34. Principios cientificos de la electroterapia. (Scientific prin-
ciples of electrotherapy.) Ibid., 16: 322-328, 1879.
35. Discusion del “Informe del Dr. J. J. Rovira sobre una fabrica
de jabon.” (Discussion on “The report of Dr. J. J. Ro-
vira on the manufacture of soap.”) Ibid., 16: 333-336,
J879.
36. Discusion del “Informe sobre secuestracion de los lazaros”
de Dr. Jose I. Torralbas. (Discussion on “The report on
the segregation of lepers” by Dr. Jose I. Torralbas.)
Ibid., 16: 363-371, 1879.
37. Higiene publica. La lepra. (Public hygiene. Leprosy.)
Ibid., 16: 428, 1879.
38. Discusion del “Informe sobre secuestracion de los lazarinos”
del Dr. Tomas M. Govantes. (Discussion on “The re-
port of segregation of lepers” by Dr. T. M. Govantes.)
Ibid., 16: 471, 1879.
39. El mosquito hipoteticamente considerado como agente de
transmision de la fiebre amarilla. (The mosquito hypo-
thetically considered as the agent of transmission of yel-
low fever.) (Read before the Royal Academy of Havanaj,
Aug. 1881.) A. de la A., 18: 147-169, 1881. Also: Rev.
de la A. M-F. de la I. de C., 2: 264-272; 354-362, 1902.
Also, in English: Ibid., 273-281; 362-370. Also: 4 0 ,
Havana, 1902. Also: 30 pp., Mexico, A. Carranza y
Comp., 1906.
54.8 Medical Classics
40. Discusion del trabajo del Dr. Santos Fernandez acerca de
“La perdida de la vista en la fiebre amarilla.” (Discus-
sion of the work of Dr. S. Fernandez on The loss of
vision in yellow fever.” A. de la A., 18: 212-213, 1881.
41. Morion del Dr. Finlay, para crear una comision permanente
de fiebre amarilla, Feb. 29, 1880. (Motion of Dr. Finlay,
to create a permanent commission of yellow fever.)
Arch, de la S. de E. C. de la H., 1: 103-105, 1881.
42. Reglamento para la Comision del estudio de la fiebre ama-
rilla. (Regulations for the commission for the study of
yellow fever.) Arch, de la S. de E. C. de la H., 1 : 133 -
136, 1881.
43. Comision de fiebre amarilla. Estado de trabajos por ella
ejecutados durante el pasado trimestre. (Commission of
yellow fever. Account of the work performed by it dur-
ing the past three months.) Ibid., i: 182-184, 1881.
44. Notas acerca de la filaria hematica en los animales y en el
hombre. (Notes on the Filaria hematic in animals and
in man. A. de la A., 18: 373-376, 1881.
45. Patologia vegetal. Enfermedad de los cocoteros. (Vege-
table pathology. Disease of the cocoa tree.) Ibid., 18:
398-400; 405-406, 1881.
46. Communication of Dr. Finlay, on the transmission of yellow
fever through an intermediary agent, to the International
Sanitary Conference of Washington 1881. Inter. Sani-
tary Conf., Protocols of the proceedings No. 7: 108-110,
1881. Also, extract: A. de la A., 17: 449-495, 1880.
Also, abstr.: Gac. M. de la H., 3: 175-177; 197-199; 218-
219, 1881.
4/. Informe reglamentario de la Comison de fiebre amarilla.
Pour su Presidente, el Dr. Carlos Finlay. (Regulatory
report of the Commission of yellow fever. By the Presi-
dent, Dr. C. Finlay.) Arch, de la S. de E. C. de la H.,
2: 98-109, 1882.
48. Consideraciones acerca de algunos casos de filariosis ob-
servados en la Habana. (Considerations of some cases
of filariosis observed in Havana.) A. de la A., 19: 40-51,
Carlos Juan Finlay 549
49. Patogenia de la fiebre amarilla. (Pathogenesis of yellow
fever.) Ibid., 160-178, 1882. Also: C. M-Q. de la H.,
9: 60-64; 119-125; 168-175, 1883.
50. Opinion de Finlay sobre la contagiosidad de la lepra. (Ob-
servations of Finlay on the contagiousness of leprosy.)
A. de la A., 19: 184, 1882.
51. Histologia. Consideraciones acerca de los estudios reciente-
mente practicados sobre la hemoglobina y su medicion
con un espectro-fotometro. (Histology. Consideration
of recent practical studies on hemoglobin and its measure-
ment with a spectro-photometer.) Ibid., 19: 302-305,
1882.
52. Exposicion de Amsterdam; morion del Dr. Finlay, delegado
de la Academia en la subcomision habanera. (Exposi-
tion of Amsterdam; motion of Dr. Finlay.) Ibid., 19:
309-311,1882.
53. Nuevos datos acerca de la relacion entre la fiebre amarilla
y el mosquito. (New data on the relation between yellow
fever and the mosquito.) Ibid., 19: 455-466, 1882.
54. Opinion del Dr. Grancher sobre algunas preparaciones des-
tinadas a comprobar la teoria patogenica de la fiebre
amarilla. (Opinion of Dr. Grancher on some of the
preparations designed to prove the pathogenic theory of
yellow fever.) Ibid., 19: 487-489, 1882.
55* Correspondence. A monsieur le docteur A. Le-Roy de
Mericourt, Directeur des Archives de Medecine Navale.
(Correspondence. To Dr. A. Le-Roy de Mericourt.)
Arch, de med. nav., Paris, 39: 307-309, 1883.
56. Resena de los experimentos de Grawitz y de Leber acerca
de la inocuacion de hongos microscopicos en el organismo
animal. (Description of the experiments of Grawitz and
Leber on the inoculation of microscopic amounts of toad-
stool into animals.) A. de la A., 20: 154-161, 1883.
57. Informe acerca de una “Estadistica medica demografica de
la ciudad de Barcelona durante el ano 1882” y “Cuadro
demografico-sanitario-meteorologico de la ultima epi-
demia de sarampion observada en la antedicha ciudad
(1881-1882)” remitidos por el Dr. Jose A. Nin y Pulles,
j^o Medical Classics
en opcion al titulo de academico corresponsal. (Report
on “Vital statistics of the city of Barcelona in 1882” and
“Sanitary, meteorological and vital statistics in the last
epidemic of measles observed in that city (1881—1882)
transmitted by Dr. J. A. Nin y Pulles, candidate for
corresponding membership.) Ibid., 20: 288-290, 1883.
58. Discusion con motivo de una nota traducida por el doctor
Mestre acerca de la teoria parasitaria aplicada a las afec-
ciones malaricas. (Discussion of an account submitted
by Dr. Mestre on the parasitic theory of malarial affec-
tions.) Ibid., 20: 293-295, 1883.
59. Transmision experimental de la osteo-mielitis aguda, y
deducciones relativas a la inoculation de la fiebre amarilla.
(Experimental transmission of acute osteomyelitis, and
deductions relative to the inoculation of yellow fever.)
Ibid., 20: 379-383, 1883.^
60. Reffexiones sobre la anestesia por el recto. (Reflections on
anesthesia by rectum.) Ibid., 20: 552, 1883.
61. Comunicacion relativa a la transmision del agente colerigeno
por el agua. (Communication relative to the transmis-
sion of the choleriform agent by water.) Ibid., 21 : 168—
169, 1884.
62. Opuntes sobre la historia primitjva de la fiebre amarilla.
(Notes on the early history of yellow fever.) Ibid., 21:
265-291, 1884.
63. Hongo encontrado en la fiebre amarilla. (Toadstools dis-
closed in yellow fever.) Ibid., 21 : 330, 1884.
64. Informe acerca de una memoria sobre fiebre amarilla con
opcion al titulo de Socio corresponsal. (Report concern-
ing a memoir on yellow fever with choice of title of a
corresponding member.) Ibid., 21: 401-414, 1884.
65. Objeciones hechas al bacilo colerigeno de Koch. (Objec-
tions made to the choleriform bacillus of Koch.) Ibid.,
21:466-473,1884.
66. Consulta sobre el restablecimiento de la vista en un ojo a
consecuencia de una lesion del otro. (Opinion on the
restoration o eyesight following an injury to the opposite
eye.) Ibid., 21: 504-505, 1884.
Carlos Juan Finlay 551
67. Peripetias del microbio del colera. (Vicissitudes of the
microbe of cholera.) Ibid., 21 : 521-522, 1884.
68. Patogenia de la fiebre amarilla. (Pathogenesis of yellow
fever.) Voz de Hipocrates, Mexico, 2: 163-165, 1884.
69. Fiebre amarilla experimental, comparada con la natural en
sus formas benignas. (Experimental yellow fever com-
pared with the natural type in its benign forms.) C.
M-Q. de la H., 10: 51-67; 91-106, 1884. Also: Arch, de
la S. de E. C. de la H., 12: 281-332, 1903. Also: 104
pp., 8°, Habana, 1904.
70. Contestation al discurso del Dr. D. Claudio Delgado: In-
vestigaciones del Dr. Ferran sobre el colera. (Response
to the discourse of Dr. D. C. Delgado on the investiga-
tions of Dr. Ferran on cholera.) A. de la A., 22: 39-89,
1885.
71. Nuevas considerations acerca de la historia de la fiebre
amarilla. (New considerations of the history of yellow
fever.) Ibid., 22: 104-124, 1885.
72. Estado sanitario de la Habana con relation a la fiebre
amarilla. (Sanitary condition of Havana in relation to
yellow fever.) Ibid., 22: 186-187,1885.
73. Casos clinicos de “taenia solium” y su tratamiento. (Clini-
cal cases of “tenia solium” and their treatment.) Ibid.,
'22: 284-286, 1885.
74. Casos de speticemia aguda y mortal a pesar de la profilaxis
y el tratamiento antisepticos. (Cases of acute septicemia,
fatal in spite of prophylaxis and antiseptic treatment.)
Ibid., 22: 308-322, 1885.
75. Trichinosis. (Trichinosis.) La Enc., I: 16-21 ; 63-69,
1885.
76. Trasplantacion del ojo. (Transplantation of the eye.)
Lancet, London, Dec. 15, 1885. Also: La Enc., 2: 35-
36, 1886.
77. Hematimetria en la fiebre amarilla. (Hematimetry in yel-
low fever.) C. M-Q. de la H., 11: 302-369, 1885.
78. Yellow fever; its transmission by means of the culex mos-
quito. Am. J. M. Sc., n.s. 92: 395-409, 1886.
Medical Classics
79. iBeri-beri 6 trichinosis? (Beri-beri or trichinosis?) La
Enc.j 2: 116-124, x 886.
80. <JTrichinosis 6 beri-beri? (Trichinosis or beri-beri?) Ibid.,
2: 311-312, 1886.
81. Etiologia del tetano traumatico. (Etiology of traumatic
tetanus.) Ibid., 2: 31 1-3 12, 1886.
82. Kakke, 6 beri-beri del Japan. (Kakke or beri-beri in
Japan.) Ibid., 2: $ 9 ~ 37 °> *886.
33, La circulacion en el kakke. (The circulation in kakke
(beri-beri).) Ibid., 2: 430-431, 1886.
84. La nitroglicerina en las enfermedades del corazon. (Nitro-
glycerin in diseases of the heart.) Ibid., 2: 585—586,
1886.
85. Opinion de Berenger-Feraud sur “Le traitement des abces
hepatiques.” (Opinion of Berenger-Feraud on “The
treatment of hepatic abscess.”) C. M-Q. de la H., 1 2 : 393,
1886. Also: Arch, de la S. de E. C. de la H., 3: 71-72,
1888.
86. Cultivos de sangre y ortos productos de la fiebre amarilla.
(Cultures of the blood and other products of yellow
fever.) A. de la A., 23: 266-270; 346-349, 1886. Also:
C. M-Q. de la H., 12: 487-490, 1886. Also: La Enc., 2:
462-464, 1886. Also: Rev. Enciclo. de Cien. Med., Fis.
y Natur. de la H., I: 1 55-1 57, 1886.
87. Cultivos de fiebre amarilla. (Cultures of yellow fever.)
A. de la A., 23: 428, 1886.
88. Instalacion de un laboratorio bacteriologico. By C. Del-
gado and Finlay. (Installation of a bacteriologic labora-
tory.) Ibid., 23: 492-501, 1886.
89. Investigaciones sobre fiebre amarilla. (Investigations con-
cerning yellow fever.) Ibid., 24: 104-114, 1887. Also:
Rev. de C. M., 20, July 30, 1887.
90. Relacion entre los cultivos recientes de fiebre amarilla y
los observados el ano anterior. With C. Delgado. (Re-
lation between recent cultures of yellowy fever and those
observed in the previous year.) A. de la A., 24: 166-169,
1887.
Carlos Juan Finlay 553
91. Colonias de tetragenos sembrados por mosquitos. (Col-
onies of tetragenus spread by the mosquito.) Ibid., 24:
205-210, 1887.
92. Informe sobre las obras del Dr. A. Jacobi presentadas con
opcion al titulo de miembro corresponsal. (Report on
the work of Dr. A. Jacobi, presented as a candidate for
corresponding membership.) Ibid., 24: 210-217, 1887.
93. Del micrococo tetrageno de la fiebre amarilla. (The micro-
coccus tetragenus of yellow fever.) With C. Delgado.
Ibid., 24: 434-446, 1887. Also, abstr.: Rev. de C. M.
32, Feb. 20, 1888.
94. Refutation al Dr. Gibier de las explicaciones dadas acerca
de un tubo bacteriologico sembrado por el mismo. (Refu-
tation to Dr. Gibier on the explanation given the subject
of a bacteriologic tube sown by himself.) By C. Delgado
and Finlay. A. de la A., 24: 461-477, 1887. Also,
abstr.: Rev. de C. M., 33, Mar. 5, 1888.
95. Relation entre los factores etiologicos y la evolution de la
fiebre amarilla. (Relation between the etiologic factors
and the evolution of yellow fever.) A. de la A., 24: 537—
546, 1887. Also: Rev. de C. M., 34, Mar. 20, 1888.
96. Resumen de las investigaciones sobre tetragenos en la fiebre
amarilla. (Resume of the researches on the tetragenus
in yellow fever.) With C. Delgado. A. de la A., 24:
590-601, 1887. Also: Rev. de C. M., 38, May 20, 1888.
97. Contestation al Dr. Tamayo. (Reply to Dr. Tamayo.)
With C. Delgado. Rev. de C. M., 25, Oct. 15, 1887.
98. Etiologia y profilaxis de la fiebre amarilla; estudio compara-
tive de los trabajos ultimamente realizados sobre la ma-
teria. (Etiology and prophylaxis of yellow fever; com-
parative study of the work ultimately accomplished on
the subject.) With C. Delgado. 14 pp., 1 p., 8°, Ha-
bana, 1887.
99. Estado actual de nuestros conocimientos, tacante a la fiebre
amarilla. (Actual state of knowledge of yellow fever.)
La Enc., 3: 102-105; 435-443, 1887. Also: Imp. La
Propaganda Literaria. Habana, 1887.
Medical Classics
100. The microbe of yellow fever. Medical Record, N. Y., 33:
622, 1888.
101. The bacteriology of yellow fever. Lancet, Lond., 2: 445—
446. 1888. Also in Spanish: Rev. de C. M., 46, Sept. 20,
1888.
102. Comunicacion sobre el micrococcus febris flavae. (Com-
munication on the micrococcus febris flavae.) With C.
Delgado. A. de la A., .25: 276-278; 458, 1888. Also,
abstr.: Rev. de C. M., 47, Oct. 1888.
103. Resumen de nuestras investigaciones sobre etiologia de la
fiebre amarilla en el ano de 1888 a 1889. (Resume of our
researches on the etiology of yellow fever during the year
1888 to 1889.) With C. Delgado. A. de la A., 25: 739-
753. 1888. Also, abstr.: Rev. de C. M., 4: 76-78; 91-92,
1889.
104. Sur le micrococcus versatilis (Sternberg). (On the micro-
coccus versatilis (Sternberg).) By C. Delgado and C.
Finlay. J. de 1 ’anat. et physiol., 25: 223, 1889.
105. Diagnostico bacteriologico del muermo. (Bacteriologic
diagnosis of glanders.) Rev. de C. M., 4: 138-139, 1889.
106. Opinion personnelle du Docteur Finlay sur un rapport de
Docteur Tamayo sur trois chevaux malades de la morve . . .
(Personal opinion of Dr. Finlay on Dr. Tamayo’s report
of three horses ill with glanders. . .) Rev. de la C. M.,
4; 176-179, 1889. Also: A. de la A., 26: 238-243, 1889.
107. Resultado de los experimentos comparativos hechos sobre
el micrococco “tetragenus versatilis.” (Result of com-
parative experiences made on the micrococcus “Tetragenus
versatilis.”) With C. Delgado. A. de la A., 26: 739-
753 > *889. Also, abstr.: Rev. de C. M., 5: 130, 1889.
108. Estadistica de las inoculaciones con mosquitos contaminados
en enfermos de fiebre amarilla. (Statistics of inoculations
made with mosquitoes contaminated with the disease of
yellow fever.) With C. Delgado. A. de la A., 27: 459-
469; 501-519, 1890. Also: Rev. de C. M., 5: 294-295,
1890. Also: 33 pp., 8°, Habana, Alvarez, 1891.
Carlos Juan Finlay 555
109. Investigation experimental sobre la linfa del Dr. Koch.
(Experimental investigation of the lymph of Dr. Koch.)
With C. Delgado. Ibid., 27: 737-744, 1890.
no. Inoculation by mosquitoes against yellow fever. Boston
M. & S. J., 124: 273, 1891. Also: Lancet, London, Jan.
31, 1891. Also, in Spanish: Rev. de C. M., 1891.
in. Inoculation for yellow fever by means of contaminated
mosquitoes. Am. J. Med. Sc., 102: 264-268, 1891.
1 1 2. Comunicacion acerca de un nuevo recurso terapeutico en el
tratamiento de la fiebre amarilla. (Communication on
the subject of a new therapeutic method in the treatment
of yellow fever.) A. de la A., 29: 202-209, 1892. Also:
Rev. de C. M., 7: 181-183, 1892.
1 13. Yellow fever, before and after the discovery of America.
Climatologist, Phila., 2: 338-349, 1892.
1 14. Tratamiento del colera. (Treatment of cholera.) Prog.
Med., 4: 295-299, 1892. Also: Arch, de la S. de E. C. de
la H., 5: 331-338, 1895.
1 15. Concordancia entre la filologia y la historia en epidemiologia
primitiva de la fiebre amarilla. (Concordance between
the philology and the history in a primitive epidemic of
yellow fever.) 28 pp., 4 0 , Merida de Yucatan, Imp.
Mercantil, 1892. Also: C. M-Q. de la H., 23: 167-182,
1897. Also: 16 pp., 8°, Habana, 1897.
1 16. Yellow fever immunity. Modes of propagation. Mosquito
theory. Cofnptes Rendus et Memoires du Huitieme Con-
gres International d’Hygiene et de Demographie, tenu a
Budapest du 1 au 9 Septembre 1894, pp. 702-706.
1 17. Patologia medica. Fiebre amarilla en los criollos. (Medi-
cal pathology. Yellow fever among creoles.) A. de la
A., 31: 190-191, 1894.
118. Yellow fever. Edinburgh M. J., 40: 35-45; 328-335; 4I4-
421, 1894. Also, in Spanish: C. M-Q. de la H., 21 : 143-
151; 171-178; 202-205; 226-233; 255-260, 1895. Also:
30 pp., 4 0 , Habana, Alvarez, 1895.
55 &
Medical Classics
1 19. The "tetragonococcus” or “tetracoccus versatilis” and yel-
low fever. Edinb. M. J., 41 : 5 i 3 ~' 5 2 9 j i ^ 95 * Also: 18
PP-
8°, Edinburgh, Oliver & Boyd, 1895. Same, in
Spanish: A. de la A., 3a: 225-245, 1896. Same, abstr.:
Prog. Med., 6: 175—178, 1894. . ,
120. Fiebre amarilla. Estudio clinico, patologico y etiologico.
(Yellow fever. A clinical, pathologic and etiologic
study.) 36 pp., 8°, Habana, imp. de Alvarez y Ca., 1895.
121. Communicacion acerca de un caso de “fiebre de borras” en
que pudo comprobarse la presencia del “Tetracoco versa-
til.” (Communication on the subject of a case of “fiebre
de borras” in which the presence of “Tetracoccus versa-
tilis” was proved.) Rev. de C. M., 10: 243-244, 1 895*
Also: A. de la A., 32: 299-303, 1896.
122. Nota sobre el diagnostico precoz, en un caso de fiebre
amarilla. (Note on the early diagnosis in a case of yel-
low fever.) A. de la A., 32: 303-305, 1896.
123. Apendice a la comunicacion sobre el tetracoco versatil y la
fiebre amarilla. (Supplement to the communication on
tetracoccus versatilis and yellow fever.) 8 pp., 8°, Ha-
bana, 1896.
124. La nueva tuberculosis (tuberculina) de Koch y algunos
germenes que suele contener. (The new tuberculin of
Koch and some germs which it may contain.) With J.
N. Davalos. A. de la A., 34: 234-239, 1897.
125. A plausible method of vaccination against yellow fever.
Philadelphia Med. Jour., I: 1123 only, 1898.
126. Los mosquitos considerados como agentes de transmision de
la fiebre amarilla y de la malaria. (The mosquito con-
sidered as the agent of transmission of yellow fever and
of malaria.) A. de la A., 35: 31-32, 1899. Also: New
York Med. Rec., 45: 737-739, 2 §99* Also: Rev. de la
A.M-F. de la I. de C., 2: 350-354, 1902.
iltiologia de la infeccidn hemogastrica en la fiebre amarilla.
(Etiology of hemogastric infection in yellow fever.) A.
de k A., 36: 183-190, 1899. Also: Rev. de M. y C. de
12^
Carlos Juan Finlay 557
128. Gelbes Fieber. (Yellow fever.) In Handbuch der prak-
tischen Medicin. 5: 486, 1900. Same, 2. ed., 4: 295-
299, 1906.
129. Transmision de la fiebre amarilla. (Transmission of yellow
fever.) Rev. de la A. M-F. de la I. de C., 1 : 373-376,
1901. Also: Jour. Amer. Med. Assoc., 36: 1040-1041,
1901.
130. Fiebre amarilla infantil. (Yellow fever in infants.) Rev.
de M. Trop., 2: 97-99, 1901. Also, in: Nothnagel’s
Specielle Pathologie und Therapie, V Band, IV Theil, II
Abtheilung.
131. Ensayo del suero caldas-bellinzaghi. (Testing of the serum
caldas-bellinzagbi.) By Guiteras, Finlay, Albertini and
Agramonte. Rev. de M. Trop., 2: 141-145, 1901.
132. Dos maneras distintas de transmitirse la fiebre amarilla por
el culex mosquito (Stegomyia taeniata). (Two distinct
means of transmission of yellow fever by the culex mos-
quito (Stegomyia taenia).) Ibid., 2: 185-192, 1901.
Also: Jour. Amer. Med. Assoc., 37: 1387-1389, 1901.
133. Piezas constitutivas de la trompa del culex mosquito.
(Parts constituting the proboscis of the culex mosquito.)
Arch, de la S. de E. C. de la H., 1 1 : 224-232, 1901. Also :
Rev. de M. Trop., 3: 3-10, 1902.
134. Is the mosquito the only agent through which yellow fever is
transmitted? Republic of Cuba. Sanitary Dept, of
Havana. 8 pp., 4 0 , 1902. Also: Trans. 1st Gen. Inter-
nal Sanitary Con. of Amer. Repub., Washington, pp.
67-71, 1903. Also: Rev. de la A. M-F. de la I. de C., 3:
2 45 ~ 2 S°> I 9°3- _
135. Method of stamping out yellow fever suggested since 1899.
Republic of Cuba. Sanitary Dept, of Havana, 7 f., 4 0 ,
1902. Also: Medicine, Mar., 1903. Also: Rev. de la A.
M-F. de la I. de C., 3: 179-185, 1903.
136. Reseiia de los progresos realizados en el siglo xix en el
estudio de la propagacion de la fiebre amarilla. Tercer
Congreso Medico Pan-Americano. Actas de las sesiones
y Memorias presentadas. (Review of the progress made
Medical Classics
119. The “tetragonococcus” or “tetracoccus versatilis” and yel-
low fever. Edinb. M. J., 4 I: 5 1 3 - 5 2- 9 > 1 ^ 95 * Also: 18
pp., 8°, Edinburgh, Oliver & Boyd, 1895. Same, in
Spanish: A. de la A., 245, 1896. Same, abstr.:
Prog. Med., 6: 175-178, 1894.
iao. Fiebre amarilla. Estudio clinico, patologico y etiologico.
(Yellow fever. A clinical, pathologic and etiologic
study.) 36 pp., 8°, Habana, imp. de Alvarez y Ca., 1 895.
121. Communicacion acerca de un caso de “fiebre de borras” en
que pudo comprobarse la presencia del “Tetracoco versa-
til.” (Communication on the subject of a case of “fiebre
de borras” in which the presence of “Tetracoccus versa-
tilis” was proved.) Rev. de C. M., 10: 243-244, 1895.
Also: A. de la A., 32: 299-303, 1896.
122. Nota sobre el diagnostico precoz, en un caso de fiebre
amarilla. (Note on the early diagnosis in a case of yel-
low fever.) A. de la A., 32: 303-305, 1896.
123. Apendice a la comunicacion sobre el tetracoco versatil y la
fiebre amarilla. (Supplement to the communication on
tetracoccus versatilis and yellow fever.) 8 pp., 8°, Ha-
bana, 1896.
124. La nueva tuberculosis (tuberculina) de Koch y algunos
germenes que suele contener. (The new tuberculin of
Koch and some germs which it may contain.) With J.
N. Davalos. A. de la A., 34: 234-239, 1897.
125. A plausible method of vaccination against yellow fever.
Philadelphia Med. Jour., i: 1123 only, 1898.
126. Los mosquitos considerados como agentes de transmision de
la fiebre amarilla y de la malaria; (The mosquito con-
sidered as the agent of transmission of yellow fever and
of malaria.) A. de la A., 35: 31-32, 1899. Also: New
ork Med. Rec., 45: 737-739, *899. Also: Rev. de la
A. M-F. de la I. de C., 2: 350-354, 1902.
127. Etiologia de la infecddn hemogastrica en la fiebre amarilla.
(Etiology of hemogastric infection in yellow fever.) A.
de la A., 36: 183-190, 1899. Also: Rev. de M. y C. de
la ^ : liy—i 22, igoo ,
Carlos Juan Finlay 557
128. Gelbes Fieber. (Yellow fever.) In Handbuch der prak-
tischen Medicin. 5: 486, 1900. Same, 2. ed., 4: 295-
299, 1906.
129. Transmision de la fiebre amarilla. (Transmission of yellow
fever.) Rev. de la A. M-F. de la I. de C., i: 373-376,
1901. Also: Jour. Amer. Med. Assoc., 36: 1040-1041,
1901.
130. Fiebre amarilla infantil. (Yellow fever in infants.) Rev.
de M. Trop., 2: 97-99? 1901. Also, in: Nothnagel’s
Specielle Pathologie und Therapie, V Band, IV Theil, II
Abtheilung.
131. Ensayo del suero caldas-bellinzaghi. (Testing of the serum
caldas-bellinzagbi.) By Guiteras, Finlay, Albertini and
Agramonte. Rev. de M. Trop., 2: 141-145, 1901.
132. Dos maneras distintas de transmitirse la fiebre amarilla por
el culex mosquito (Stegomyia taeniata). (Two distinct
means of transmission of yellow fever by the culex mos-
quito (Stegomyia taenia).) Ibid., 2: 185—192, 1901.
Also: Jour. Amer. Med. Assoc., 37: 1387-1389, 1901.
133. Piezas constitutivas de la trompa del culex mosquito.
(Parts constituting the proboscis of the culex mosquito.)
Arch, de la S. de E. C. de la H., 1 1 : 224-232, 1901. Also :
Rev. de M. Trop., 3: 3-10, 1902.
134. Is the mosquito the only agent through which yellow fever is
transmitted? Republic of Cuba. Sanitary Dept, of
Havana. 8 pp., 4 0 , 1902. Also: Trans. 1st Gen. Inter-
nal Sanitary Con. of Amer. Repub., Washington, pp.
67-71, 1903. Also: Rev. de la A. M-F. de la I. de C., 3:
2 45 _ 2 5 °> i 9 ° 3 * _
135. Method of stamping out yellow fever suggested since 1899.
Republic of Cuba. Sanitary Dept, of Havana, 7 f., 4 0 ,
1902. Also: Medicine, Mar., 1903. Also: Rev. de la A.
M-F. de la I. de C., 3: 179-185, 1903.
136. Resena de los progresos realizados en el siglo xix en el
estudio de la propagacion de la fiebre amarilla. Tercer
Congreso Medico Pan-Americano. Actas de las sesiones
y Memorias presentadas. (Review of the progress made
558 Medical Classics
in the igth century in the study of the propagation of
yellow fever.) Habana. it * 95 "” 1 tyOQ-. Also, in-
complete: Rev. de M. Trop., 2: i 9 01 *
137* Agreement between the history of yellow fever and its
transmission by the culex mosquito (Stegomyia of Theo-
bald). Jour. Amer. Med. Assoc., 38: 993-996, 1902.
138. Cartas estadisticas del Dr. Carlos J. Finlay. (Statistical
letters of Dr. Finlay.) Informe Sanitario y Demografico
de la Republica de Cuba. May 1902-Dec. 1908.
139. Concepto probable de la naturaleza y el ciclo vital del ger-
men de la fiebre amarilla. (Probable nature and life-cycle
of the yellow fever germ.) Rev. de M. Trop., 4: 49-54,
1903. Also, in English: 13 pp., 4 0 , 1903.
140. The transmission of yellow fever. Letter. Jour. Amer.
Med. Assoc., 40: 1659-1660, 1903.
141. Fiebre amarilla experimental segun la tecnica moderna.
(Yellow fever according to the modern technique.) Arch,
de la S. de E. C. de la H., 12: 406-444, 1903. Also:
Rev. Med. Cub., 4: 47-79; 1 60-1 61, 1904.
142. Transmission de la fievre jaune por le moustique culex.
Manuscript de 1891. (Transmission of yellow fever by
the culex mosquito. Manuscript of 1891.) Rev. de M.
Trop., 4: 134-143, 1903.
143. New aspects of yellow fever etiology, arising from the ex-
perimental findings of the last three years. Rev. de la
A. M-F. de la I. de C., 3: 477-480, 1903. Also: Jour.
Amer. Med. Assoc., 42: 430-431, 1904. Also: C. M-Q.
de la H., 30: 11-13, 1904.
144. "iellow fever: historical sketch of the disease, its etiology
and mode of propagation. Reference Handbook of Med.
Sc., 8: 322-332, 1904.
145. Los leucocitos. Sugestiones acerca del papel que repre-
sentan en ia nutricion celular y en la formacion de toxinas,
lismas, etc., y de los respectivos anticuerpos. (The leu-
cocytes. Suggestions on the r 61 e which they play in
cellular nutrition and in the formation of toxins, lys'ms.
Carlos Juan Finlay 559
etc., and the respective antibodies.) A. de la A., 41:
82-91; 102-108, 1904.
146. Nota ampliativa de mi trabajo sobre “Los leucocitos.”
(Supplementary note on my work on “The leucocytes.”
Ibid., 41: 128-129. Also: Rev. Med. Cub., 5: 1— 17,
I 9° 4 *
147. Manual de practica sanitaria para uso de jefes e inspectores
de sanidad, medicos, funcionarios, etc., de la Republica de
Cuba. (Manual of practical sanitation for the use of
, chiefs and inspectors of sanitation, doctors, etc. of the
Republic of Cuba.) xvi., 1114 pp., 22| cm., Habana,
1905.
148. Estado sanitario de la Isla de Cuba despues de la procla-
mation de la Republica. (Sanitary conditions on the
islands of Cuba after the proclamation of the Republic.)
Rev. de M. Trop., 6: 1-9, 1905.
149. President’s address. American Public Health Association,
Havana, Cuba, 1905. Ann. Report Amer. Pub. Health
Assoc., 1905.
150. Casos de fiebra amarilla en la Habana en Octubre de 1905.
La fiebre amarilla en la Habana. (Case of yellow fever
in Havana in October, 1905. Yellow fever in Havana.)
Bol. de las D. ocurr. en el T. M. de la H., Oct.-Dec., 1905.
Also: Rev. de M. Trop., 7: 6-16, 1906.
1 51. Nota preliminar sobre la importancia de ciertos factores
secundarios en la mortalidad y transmisibilidad de la
tuberculosis pulmonar. (Preliminary note on the im-
portance of certain secondary factors in mortality and
transmission of pulmonary tuberculosis.) Actos y Tra-
bajos del Primer Congreso Medico Nacional. Habana.
pp. 434~435> May 20-23, l 9 °$-
152. Importancia de ciertos factores secundarios en el desarrollo
de la tuberculosis pulmonar y en la mortalidad producida
por la misma. (Importance of certain secondary factors
in the development of pulmonary tuberculosis and in the
mortality produced by that disease.) A. de la A., 42:
62-76, 1905. Also: Rev. de M. Trop., 6: 97-109, 1905.
^60 Medical Classics
JCJ. Del mosquito como factor etiologico de la fiebre amarilla.
(The mosquito as the etiologic factor in yellow fever.)
Rev. Med. Cub., 9: 3-8, 1906. Also: Arch, de la S. de
E. C. de la H., 13: 140-147. * 9 0 7 - Also: C - de Ia
H., 33: 232-234., 1907.
154. Casos, al paracer, tlpicos de fctero catarral simple como
secuela posible de ataques benignos e ignorados de fiebre
amarilla. (A case presenting the appearance of typical,
simple, catarrhal jaundice, possibly the result of a benign
and undiagnosed attack of yellow fever.) A. de la A.,
43: 202-205, 1907. Also: Rev. de M. y C. de la H., 12:
45 " 5 °. * 9 07 •
155. Atmospheric temperature as an essential factor in the propa-
gation of yellow fever. XIV Internat. Congr. Hyg. &
Demography, Berlin, 1907. Havana, Printing Office,
1907. Also, in Spanish: Rev. Med. Cub., 12: 130-147,
1908.
156. Discurso leido por el Dr. Carlos J. Finlay en el Aula Magna
de la Universidad de la Habana, al recibir la medalla
“Mary Kingsley/’ (Discourse read by Dr. Carlos J.
Finlay in the Great Amphitheatre of the University of
Havana, when he received the “Mary Kingsley” medal.)
Boletm oficial del Departamento de Estado de la Secre-
tarfa de Estado y Justicia. Habana. 4: 338-339, 1907.
* 57 * Discurso de gracias del doctor Carlos J. Finlay (Officier de
la Orden la Legion de Honor (France).) (Discourse of
thanks by Dr. Finlay.) A. de la A., 45: 356-360, 1908.
158. Trabajos sciectos del Dr. Carlos J. Finlay. (Selected papers
of Dr. Carlos J. Finlay.) Habana, 1912. xxxiv, 657 pp.,
port., 26 cm., Spanish and English.
BIBLIOGRAPHY OF BIOGRAPHIES
Bl0g i893- by F ’ Grande R ° ssi ' H % iene > Habana, 3: 149-152,
Biography by B. Lee. Escuela de Med., Mexico, 20: 98-106,
1905. y
Biography by J. Guiteras. Rev. M6d. Cub., Habana, 10: 233-
247, 1907. * 0J
Carlos Juan Finlay 561
Biography. Rev. de M. y C. de la H., 13: 549-552, 1908.
Biography. A. de la A., 45: 343, 1908-9.
Informe acerca de los trabajos cientifxcos del Dr. Carlos J. Finlay.
By C. Delgado and J. LeRoy. Ibid., 45: 214-237.
The work of Finlay in respect of insect borne disease. By J.
Guiteras. Lancet, Lond., I: 1715, 1910;
El Dr. Carlos J. Finlay. By Juan Guiteras. 12 pp., 8°, Habana,
Sierra, 191a.
Biography by W. C. Gorgas. Am. J. Pub. Health, 5: 1 177, 1915.
Biography. Boston M. & S. J., 173: 444, 1915.
Biography. Brit. M. J., 2: 626, 1915.
Biography by E. B. Barnet. California State J. M., 13: 476-
478, 1915.
Biography by J. Santos Fernandez. C. M-Q. de la H., 41 : 209-
212, 1915.
Biography. Med. Rec., 88: 366, 1915.
Biography. J. A. M. A., 65: 814, 1915.
Biography by A. Agramonte. New Orleans M. & S. J., 69: 55-
60, 1915.
Biography. New York M. J., 102: 468, 1915.
Biography by J. LeRoy. Rev. de M. y C. de la H., 20: 349-
354* W.
Biography. Vida Nueva, Habana, 7: 170-178, 1915.
Dr. Carlos J. Finlay. Address delivered by W. C. Gorgas, at
the 43d annual meeting of the American Public Health Asso-
ciation, Rochester, N. Y., Sept. 7, 1915. 2 1., 4°, n.p., 1915.
Dr. Carlos J. Finlay’s positive cases of experimental yellow fever.
By C. E. Finlay. New Orleans M. & S. J., Nov. 1916.
Biography by A. Agramonte. Tr. Am. Soc. Trop. Med r , N. Orl.,
10: 26-31, 1916.
Carlos Finlay on the house mosquitoes of Habana. By F. Knob.
Proc. Pan-Am. Scient. Cong., 1915-16, Wash., 9: 107-110,
I 9 I 7*
Biography. San. y Benefic. Bol. Ofic., Habana, 20: 1-197,
1918.
Inauguration del monumento erigido a Finlay en la Secretaria de
sanidad y beneficencia el 25 de marzo de 1916; alocucion del
^62 Medical Classics
Senor Secretario de Sanidad y Beneficenciz. By E. Nunez.
Ibid., 20: 105-107.
Discurso pronunciado en la ceremonia del descubrimiento del
busto del Dr. Carlos J. Finlay. By A. Agramonte. Ibid.,
20: 112-116.
Same. By J. Guiteras. Ibid., 20: 1 17-123.
Dr. Osier’s address on “The Nation and the tropics” and Dr.
Finlay. By J. Guiteras. Ibid., 20: 124-128.
Biography. American Review of Reviews, p. 386, Apr. 1920.
Biography. New Orleans M. & S. J., 74: 222, 1921.
Ein Denkmal fur Carlos Finlay in Habana. By W. Hoffman.
Berl. klin. Wochenschr., 58: 1231, 1921.
Monument to Carlos Finlay in Havana. J. A. M. A., 77: 1113,
1921.
Ein Aerztedenkmal. By C. Schilling. Deutsche med. Woch-
enschr., 47: 1433, 1 921.
Biography. M. J. & Rec., 120: 605-606, 1924.
En Honor de Finlay. Bol. Ofic. san. panam., 7: 991, 1928.
Finlay and his discovery of transmission of yellow fever by a
mosquito. By J. Silverio Sainz. San. y benefic., 33 : 623-
634, 1928. Also: Actas y trab. del primer Cong, de la Asoc.
med. Panamericana, pp. 1 14-128, 1930.
Discovery of yellow fever agent. By J. Silverio Sainz. Rev.
Med. Cub., 40: 271-284, 1929.
Review of work of Finlay and of Noguchi on yellow fever. By
F. Berrios. San. y benefic., 34: 333-346, 1929.
Biography. Portrait. Med. Rev. of Rev., 25: front., 1929.
His fundamental work. By J. LeRoy y Cassa. Rev. Med. Cub.,
42: 1261-1274, 1931. Also: Gac. M. de Mexico, 63: 165-
} 11 , 19 3 2 -
Participation of author in efforts to compile Finlay’s work on his
discovery of yellow fever agent. By C. M. Garcia. C. M-
Q. de la H., 58: 303-336, 1932.
Centenary of birth; suggestion to celebrate his birthday as Pan-
American day of Medicine. By H. Abascal. Rev. de M.
y C. de la H., 38: 260-266, 1933. Also: Vida Nueva, 33:
47-53> 1934-
Carlos Juan Finlay 563
Centenary of birth. By A. Leao Velloso. Rev. de M. y C. de
la H., 38: 546-548, 1933.
Centenary of birth. By M. S. Iglesias. Rev. Med. Veracruzana,
13: 1013-1019, 19^3.
Definition of Finlayism. By F. Miranda. Ibid., 13: 1019-1021.
Work in combating yellow fever. By E. Landa. Ibid., 13:
1021-1030.
Celebration of centenary of birth. By F. Dominguez. Bull.
Acad, demed., Paris, no: 596-622, 1933. Also, abstr.: Gaz.
d. hop., 106: 1741-1743, 1933.
Centenary of birth; celebration at Academy of Medicine (Le cen-
tenaire de Finlay a l’Academie de Medecine.) Vie med., 14:
1065-1066, 1933.
Celebration of centenary of birth at Academy of Medicine, Paris.
By P. Desfosses. Presse med., 41 : 2049, 1933.
Remarks on yellow fever in honor of centenary of birth. By
W. H. Hoffmann. Rassegna internaz. di clin. e terap., 14:
1213-1220, 1933. _
Numero expecial dedicado al centenario del natalicio del Dr.
Carlos J. Finlay. C. M-Q. de la H., 59, 1933.
Importance of work on transmission of diseases by insects. By
L. O. Howard. Ibid., 59: 511-512, 1933.
Biography by C. M. Garcia. Ibid., 59: 517-521, 1933.
Biography by J. Guiteras. Ibid., 497-504, 1933.
Meeting of Academia Nacional de Medicina de Mexico to honor
Carlos Juan Finlay on centenary of birth and to celebrate
Pan-American Day of Medicine. By S. Iturbide Alvirez.
Gac. Med. de Mexico, 65: 41-51, 1934-
Work as clinician. By F. Dominguez. Rev. de M. y C. de la
H., 40: 737-743, 1935.
Docteur Carlos J. Finlay, son centenaire (1933), sa decouverte
(1881). By Francisco Dominguez. 302 pp., Paris, 1935.
Life and work. By S. Garcia Marruz. Rev. Med. Cub., 47:
106-122, 1936.
Yellow fever; means of transmission; reminiscences of work of
my father. By C. E. Finlay. Bull. Am. Coll. Surgeons, 21 :
ioo-ioi, 1936.
j-64. Medical Classics
Can the world still be ignorant of Finlay’s great work, especially
in relation to transmission of yellow fever? By L. Pastor
Guesada. C. M-Q. de la H., 6a: 566-5 V, I93 6 * .
Speech in his honor given on Day of American Medicine, Dec.
3, 1936. By A. Recio. Rev. de M. y C. de la H., 41 : 727-
73*^ 1936.
INDEX TO BIBLIOGRAPHY
Reference Year
Anesthesia by rectum 60 1883
Beri-beri 7 9 ,*° 1886
8a, 83 1886
Cancer 10 i8 74
Cataracts J 6j 17 i8 75
Cholera 2 1865
4 1868
7 i 8 73
9 i8 74
ao 1 876
61, 65, 67 1884
70 1885
1 14 189a
Cuba, climate a6 , 17 1878
Cuba, sanitation 148 1 905
Electrotherapy 34 1879
Eye, injury 66 1884
Eye, transplantation 76 1885
Filaria hematic 44 1881
Filariosis 4 8 188a
Gas-lighting i 4 1874
Glanders ; 105, 106 1889
Goitre, exophthalmic 1 1864
n . . 3 2 i 8 79
Gravitation u, 12 1874
Havana, atmosphere ^
Hemoglobin „ i882
Hepatic abscess g 5 l8 g£
Carlos Juan Finlay
J 6 J
Reference
Year
Hernia
3
1866
Leprosy
33. 36
1879
37.38
i8 79
5o
1882
Leucocytes
145^46
1904
Malaria
2 3
1877
58
1883
Mosquito
(See also Yellow fever)
133
I9OI
Nitroglycerin
84
1886
Ophthalmology
18
1875
22
1876
Osteomyelitis
59
1883
Sanitation, manual
147
1905
Septicemia
74
1885
Tenia solium
73
1885
Tetanus
8
1873
81
1886
Trichinosis
75
1885
O
OO
r-
1886
Tuberculin of Koch
1897
Tuberculosis
!5L 15 2
1905
Yellow fever
29, 30
j 879
39, 40, 41
1881
42, 43, 46
1881
47. 49
1882
53. 54-
1882
61, 63, 64
1884
68, 69
1884
7i. 7 2 . 77
1885
78. 86, 87
1886
89. 9°. 93
1887
95. 9 6
1887
98, 99
1887
IOO, IOX
1888
103
1888
5 66
Medical Classics
Reference Year
Yellow fever — concluded 108 1890
no, in 1891
1 12. 1891
113, 1 15 1892
116, 117 1894
118 1894
1 19, 120 1895
122, I23 1896
125 1898
126, I27 1899
128 I9OO
I29, I30 I90I
I32 I90I
J 34, 135 I 9° 2
j 3 6 > j 37
139, 1 40 1903
141, 142 1903
T 43 I 9°3
144 i9°4
150 1905
153 1906
*54> 155 I9°7
INTRODUCTION
Yellow fever is a disease of tropical and sub-tropical countries,
characterized by fever with jaundice, toxemia and albuminuria,
and a tendency to hemorrhage, especially from the stomach.
This disease has been prevalent since the days of early history
in the West Indies, in countries bordering on the Caribbean Sea,
and on the west coast of Africa. Occasionally it has extended to
the southern region of the United States, especially along the
Atlantic seaboard. Serious epidemics of yellow fever have
occurred as far north as Boston. Perhaps the most famous and
serious attack of this disease in the United States took place in
Philadelphia in 1793. In that city of 40,000 people, over 4,000
died in the period from August through November. Severe
epidemics occurred in the United States occasionally throughout
the 19th century and as late as 1903 a severe epidemic occurred in
Texas near the Mexican Border.
Yellow fever has always been prevalent in Cuba. On that
Island there was born in 1833 Carlos J. Finlay to whom goes the
credit for first insisting that yellow fever was spread by mos-
quitoes. After being educated on the continent and in the United
States, Finlay returned to his home in 1864, at the age of 31, and
started a medical practice. Finlay's interest in yellow fever
undoubtedly began at the time when he first realized that there
was such a disease. We find him during his first year of medical
practice gathering data on the climate of Havana. He was
searching for a possible explanation of the mysterious outbreaks
of yellow fever which occurred most seriously among white visitors
to the Island. The natives had some immunity but nearly every
foreigner contracted the disease within a year or two after arrival.
Finlay noticed that when a boat anchored in the harbor of Havana
and only the captain and mate came ashore, the crew being left
aboard because of fear of contracting disease, nevertheless yellow
fever broke out among the crew some time after the return of the
captain and mate, even though these people continued in perfect
health. Boats loaded at Havana sailed away to not-too-distant
ports with their holds sealed. On arrival at a suitable and
favorable port an epidemic of yellow fever broke out after the
hold was opened. Finlay noticed also that yellow fever decreased
when the temperature dropped to 50 or 60 degrees and the disease
entirely disappeared when the freezing point was reached.
Dr. Finlay attempted to find one cause of the transmission of
yellow fever which would explain all these startling facts. He
probably thought first of personal and inanimate objects which
had been in contact with patients (fomites). But transmission
by these objects could not explain all the phenomena. Next
Finlay considered flies as the go-between but this idea also had to
be discarded. Then this tireless worker decided that the mos-
quito was the agent of transmission of yellow fever.
The following pages of Finlay’s writings show the problem which
he had set himself. In the first place, he had to ' hnd out all he
could about mosquitoes existing in Cuba. Then he had to allow
certain mosquitoes to bite patients ill with yellow fever and later
these same mosquitoes to bite volunteer patients. Finlay very
early decided, and correctly so, that the species of mosauito
responsible for the transmission, was the Cutcx Cubc? 7 sts i later
called the Stegomyia Fasciatus , and still more recently Aedes
Egypti. But read in his own words, published in 1881, the story
ofFinlay’s inspiration and the experiments he performed to prove
the truth of his idea.
Unfortunately, Finlay never produced an undoubted case of
yellow fever in his experimental subjects. It has since been
found that an infected mosquito requires about twelve days_ after
biting a patient ill with yellow fever before it can give the disease
to a second victim. This fact escaped Finlay but does not detract
from the greatness of his imagination.
When the Yellow Fever Commission of the United States Army
was sent to Cuba in the last years of the 19th century their leader.
Major Walter Reed, conferred with Carlos J. Finlay on the
mosquito theory of transmission. At that time the Bacillus
icteroides of Sanarelli (Bacillus X of Sternberg) was considered
the causative agent. Reed and his Commission soon showed
that this bacillus was not the culprit and proceeded to test Finlay’s
mosquito theory. The story of Reed and his Commission (James
Carrol, Aristide Agramonte and Jesse W. Lazear who lost his life)
is a famous^ story which must be deferred until a further time.
The Commission proved that yellow fever is conveyed by the
mosquito and within a year Major William C. Gorgas was eradi-
cating yellow fever from Cuba by isolating patients ill with this
disease and eliminating the mosquitoes. In three months Havana
was free from the disease for the first time in 1 50 years. Gorgas
later applied the same methods of control of yellow fever and other
m ectious diseases in the Panama Canal Zone and made it possible
lor the Canal to be constructed. 1
More recent work on yellow fever has been carried on by Hideyo
V, ' h °’ be - tween T and 1924, isolated and cultivated the
organism Leptospira mterrogans and developed a
P p “^vaccine and curative serum for the disease.
alone- vhirWtf ^ ^nlay goes the credit for pointing out the way
along which these other workers have progressed.
El Mosquito Hipoteticamente
Considerado como Agente de
Trasmision de la Fiebre
Amarilla
Anales de la Real Academia de Ciencias Medicas, Ftsicas y Naturales,
18: 147-169, 1881.
Sehor President e. — Sres. Academicos:
Igunos anos ha, en este mismo lugar tuve la
honra de exponer el resultado de mis ensayos
alcalimetricos, con los que creo haber demos-
trado definitivamente la excesiva alcalinidad
que presenta la atmosfera de la Habana.
Quizas recuerden algunos de los Academicos
aqui presentes las relaciones conjeturales que cref poder senalar
entre ese hecho y el desarrollo de la fiebre amarilla en Cuba.
Pero de entonces aca mucho se ha trabajado, se han reunido
datos mas exactos y la etiologla de la fiebre amarilla ha podido
ser estudiada mas metodicamente que en epocas anteriores. De
ahi el que yo me haya convencido de que precisamente ha de ser
insostenible cualquiera teoria que atribuya (p. 148) el orlgen 6
la propagacion de esa enfermedad a influencias atmosfericas,
miasmaticas, meteorologicas, ni tampoco al desaseo ni al descuido
de medidas higienicas generales. He debido pues abandonar mis
primitivas creencias; y al manifestarlo aqui, he querido en cierto
modo justificar ese cambio en mis opiniones, sometiendo a la
apreciacion de mis distinguidos colegas una nueva serie de es-
569
o Medica.1 Classics
tudios experimentales que he emprendido con el fin de descubrir
el modo de propagarse la fiebre amarilla.
Debo advertir, empero, que el asunto de este trabajo nada
tiene que ver con la naturaleza o la forma en que puede exis-
tir la causa morbigena de la fiebre amarilla: me limito a admitir
la existencia de una causa material trasportable, que podra ser
un virus amorfo, un germen animal o vegetal, una bacteria etc.,
pero que constituye, en todo caso, un algo tangible que ha de
comunicarse del enfermo al hombre sano para que la enfermedad
se propague. Lo que me propongo estudiar es el medio por el
cual la materia morbigena de la fiebre amarilla se desprende del
cuerpo del enfermo y se implanta en el hombre sano. La nece-
sidad de admitir una intervention extrana a la enfermedad para
que esta se trasmita, resulta de numerosas consideraciones, al-
gunas de ellas formuladas ya por Rush y Humboldt, a principios
del siglo, y confirmadas luego por observaciones mas recientes.
La fiebre amarilla unas veces atraviesa el Oceano para ir a propa-
garse a ciudades muy distantes y de condiciones meteorologicas
muy diferentes de las del foco de donde ha provenido la infeccion;
mientras que en otras ocasiones la misma enfermedad deja de
transmitirse fuera de una zona epidemica estrecha, por mas que
la meteorologia y la topografia de los lugares circunvecinos no
revelen diferencias que expliquen ese comportamiento tan diverso
de la misma enfermedad en dos localidades, al parecer, iguales.
Admitida la ingerencia necesaria de un agente de trasmision que
explicara las anomalias senaladas, es claro que sobre ese agente
habria de recaer la influencia de todas las condiciones hasta ahora
reconocidas cor, 3 esenciales para que la fiebre amarilla (p. 149)
se propague. So era,.pues, posible buscar ese agente entre los
microzoarios ni los zoofitos, porque en esas categorias infimas de
la naturaleza animada, poco 6 nada influyen las variacionees
meteorologicas que mas suelen afectar el desarrollo de la fiebre
amarilla. Para llenar esta primera condicion fue preciso ascender
hasta la clase de los insectos, y, teniendo en cuenta que la fiebre
amarilla esta caracterizada clinica, y tambien, segun trabajos
cientes, isto ogicamente, por lesiones vasculares y alteraciones
co quimicas de la sangre, parecia natural buscar el insecto
El Mosquito 571
que hubiera de llevar las particulas infectantes del enfermo al
hombre sano entre aquellos que penetran hasta el Interior de los
vasos sangulneos para chupar la sangre humana. En fin, en
virtud de consideraciones que fuera ocioso referir, llegue a pre-
guntarme si no seria el mosquito el que trasmite la fiebre amarilla.
Tal fue la hipotesis que motivo la serie de estudios experi-
mentales que voy a exponer.
La aplicacion de las ciencias auxiliares a la Medicina suele
exigir conocimientos taii variados y tan especiales en los distintos
ramos del saber humano, que no debemos extranar la tardanza
que los estudios realizados en tal 6 cual provincia cientifica suelen
experimentar antes de poderse aprovechar en beneficio de nues-
tras investigaciones medicas. Notase particularmente esa difi-
cultad con respecto a la Historia Natural, porque las mas de sus
adquisiciones, fundadas en la observacion directa de fenomenos
naturales, para que podamos utilizarlas, casi siempre requieren
una completa revision desde el nuevo punto de vista que su apli-
cacion a las ciencias medicas implica. Solo asi se comprende el
que mas de un siglo despues que el ilustre Reaumur escribiera su
admirable memoria sobre los habitos del Mosquito, justamente
considerada como un modelo de exacta e inteligente observacion y
que, bajo un punto de vista general, parece casi agotar el asunto
de que trata, cuando, ahora seis meses, yo recurri a tan valiosa
fuente, en busca de datos que me facilitasen el estudio que me
habia propuesto, no halle los que mas falta me hacian (p. 150)
y me fue preciso, no tan solo emprender una comprobacion radical
de los datos presentados por Reaumur, para cerciorarme de que
eran tambien aplicables a los mosquitos de Cuba, sino tambien
escudrinar otros pormenores que a Reaumur y a los demas natura-
listas no les interesabe observar.
Comencemos por recordar a grandes rasgos la distribucion geo-
grafica del mosquito. En terminos generales puede decirse que
en todas partes los hay, menos en las cumbres elevadas. En
efecto, el diptero que nos ocupa, el genero Culex, que muchos
creen especial tormento de las regiones tropicales, existe, por lo
contrario, en todas las latitudes. En las regiones polares, los
Lapones al par de los habitantes de las regiones equinocciales de
$ 7 2 Medical Classics
America, no pueden tomar el alimento ni acostarse a dormir en
sus chozas, sino sumergidos en una atmosfera de humo, para
librarse de esa plaga. AI aire libre los mosquitos se les meten
por la boca y las narices; y esos hombres, a pesar de su cutis
endurecido por el frio de sus inviernos, a duras penas logran
preservarse por medio de velos saturados de grasas fetidas y
untandose el cuerpo con crema 6 manteca. En el Canada, en
Rusia, en Inglaterra, en Francia, en Espana, en toda Europa, en
Siberia, en China, en los Estados Unidos, en la America del
Norte, como enla del Sur, pululan los mosquitos. En el centro
de Africa un viajero aleman, el Dr. Schweinfurst, fue atormen-
tado por unos mosquitos de patas pintadas (spotty legged) cuya
descripcion pudiera convenir al C. mosquito de Cuba y tambien
al que el Dr. Arnold observo en Batavia, segun refiere Kirby,
considerandolo como una especie no descrita, parecida al C. annu-
latus, pero sin pintas en las alas.
Notase sin embargo en la misma distribucion geografica alguna
preferencia del mosquito a extenderse en los continentes antes
que en las islas, confirmandose asi la observacion de Humboldt
de que ese diptero es mas abundante en las riberas de los grandes
rios que no en los islotes que se encuentran en los mismos, y que
se siente menos el tormento de los mosquitos en el centro del rio
que cerca de las riberas. Quiza a esto se (p. 151) deba al que los
primeros historiadores del descubrimiento de la America no hagan
especial mencion del mosquito en las Islas, durante los primeros
viajes de Colon; pues no he encontrado mencion especial de ellos
en las Antiilas antes de 15385 & proposito de una excursion de
Hernando de Soto, cuyos soldados al atravesar un rio, cerca de
Puerto de los Principes, fueron picados de tal manera por los
mosquitos que tenian en las espaldas grandes manchas de sangre.
A la misma inmunidad relativa de las islas debese sin duda
atribuir el hecho siguiente que un viajero americano refirio al
entomologo Osten Sacker, [citado por el Dr. Taschenberg, Brehm
3 pag- 44 ^b Por el ano de 1823 no se conocian aun los mos-
quitos en las islas de Hawai; mas entre los de 1828 a 1830, un
uque viejo venido de Mejico fue abandonado en las costas de
una e e as. Pronto observaron los habitantes que al rededor
El Mosquito 573
de ese lugar aparecian unos insectos desconocidos, chupadores de
sangre. Esto desperto la atencion de los indigenas y algunos
curiosos solian venir por las tardes a dejarse picar por esos in-
sectos tan extraordinarios. Luego se propagaron los mosquitos
en esas islas y llegaron a ser una verdadera plaga.
Es cierto que el mosquito en todas las latitudes existe, mas no
en todas las localidades se encuentra en igual abundancia. Alej.
Humboldt y Bonpland, en sus viajes a la America equinoccial,
dicen: “El tormento de los mosquitos y de los zancudos no es
tan general bajo la zona torrida como se cree generalmente. En
las mesetas elevadas mas de 400 toesas sobre el nivel del Oceano,
en las muy secas llanuras distantes de los grandes rios, por
ejemplo, Cumana y Calabozo, no hay sensiblemente mas marin-
guinos que en la parte mas habitada de Europa.” La influencia
de la sequedad y distancia de los rios, senalada por esos viajeros,
desde luego se comprende, toda vez que la larva del mosquito y
su ninfa son acuaticas, y que, para propagarse, el insecto adulto
tiene que depositar sus huevos en el agua. En cuanto al impedi-
ment que las alturas oponen a su propagacion, estimo que sera
consecuencia de la misma dificultad que esos dipteros siempre
experimentan en el vuelo ascendente (p. 152) despues de haberse
llenado de sangre, maxime si se trata de especies como la del
C. mosquito, cuyas alas son tan pequenas, puesto que esa difi-
cultad no po dra menos que aumentar por efecto de la rare-
faccion del aire en las alturas considerables. En tal caso, se
comprende que el mosquito se aparte instintivamente de esos
lugares. Tam bien refieren los viajeros antes citados que el buen
misionero Bernardo Zea se habia construido una habitacion sobre
un tablado de troncos de palma, donde ellos iban por las noches
a secar las plantas que habian recogido y a redactar su Diario.
“El misionero habia observado con razon, dicen, que los insectos
abundan comunmente en la capa mas baja de la atmosfera, que
se acerca de la tierra hasta unos 12 6 15 pies de altura.” Mas
adelante agregan esos autores: “a medida que se sube hacia la
llanura 6 meseta de los Andes, estos insectos desaparecen y alii
se respira un aire puro ... a doscientas toesas de altura ya no se
temen los zancudos 6 musticos.”
^74 Medical Classics
Historicamente el mosquito es uno de los insectos mas antigua-
mente observados. Aristoteles y Plinio hacen referenda a su
trompa, que sirve a la vez para horadar la piel y chupar la sangre.
El historiador griego Pausanias [citado por Taschenberg] men-
ciona la ciudad de Myus, en Asia menor, situada en una ensenada
cuya comunicacion con el mar vino a cerrarse luego; cuando el
agua del lago que as! se formara dejo de ser salada, resulto tal
plaga de mosquitos, que los habitantes abandonaron la ciudad
y se trasladaron a Mileto. Asi tambien, leemos en las Decadas
de Herrera, Juan de Grijalva, cuando por primera vez descubrio
las costas de Nueva Espana, el ano de 1518, hubo de ocupar con
su gente la isleta que nombro San Juan de Ulua, teniendo que
hacer sus chozas “encima de los mas altos medanos de arena de
la isleta, por huir de la importunidad de los mosquitos.” De
alii mismo tuvo luego que salir al cabo de siete dias, “no se
pudiendo valer de los mosquitos,” y Bernal Diaz del Castillo
tuvo que irse a unos adoratorios de los indios, “huyendo de la
molestia de los mosquitos.” En fin, en 1519, casi en el mismo
(p. 153) sitio donde hoy se levanta la moderna Veracruz “los
mosquitos zancudos, dice Herrera, y los chicos que son peores,
fatigaban la gente de Cortes.”
Dos especies de mosquitos he observado en la Habana desde
el mes de Diciembre proximo pasado que vengo estudiando esos
insectos. Una es grande, de color amarillo, con patas largas y
delgadas, sin pintas notables; supongo que sea el identico zan-
cudo que fatigaba la gente de Cortes en los arenales de San Juan
de Ulua por el ano de 1 5 1 9 > Y e l Culex cubensis descrito en la
obra de La Sagra. Su cuerpo, medido desde la ralz de la trompa
hasta la extremidad anal, tiene de 5 a 7 milimetros de longitud.
r s ^ a specie sale exclusivamente de noche, despues de las nueve
o diez, } prosigue sus molestas evoluciones hasta la madrugada:
a ella ban pertenecido casi todos los mosquitos que he encon-
trado en los mosquiteros, donde una vez que se han llenado de
-angre, suelen permanecer parte del dia, mientras digieren la
sangre que an chupado. La otra especie es el Culex Mosquito,
quenuestro distinguido naturalista cubano, D. Felipe Poey, Ilevo
a Fans en los anos 1817 6 1820, donde fu6 clasificado por M.
El Mosquito 575
Robineau Desvoidy. He observado dos variedades de esta es-
pecie: una, la mayor, esbelta y vigorosa, de color gris oscuro,
mide poco menos que el zancudo; y otra, mas pequena, de cuatro
a cuatro y medio milimetros de longitud. No me he ocupado en
buscar caracteres diferenciales entre estas dos variedades de una
misma especie, puesto que la diferencia de sus dimensiones bas-
taba para mi objeto actual. Ambas variedades del C. mosquito
presentan los distintivos siguientes: su cuerpo es oscuro, a veces
casi negro 6 color de acero; la superficie ventral y la superior del
abdomen estan como reforzadas por una capa espesa anillada de
bianco, predominando a veces la parte blanca, de manera que
parecen bianco 6 blanquecino el fondo y oscuros los anillos. En
cada lado del abdomen se ven dos hileras de seis puntos anacara-
dos, entre los cuales se coloca la membrana transparente que ha
de distenderse para dejar ver la sangre u otro liquido que el
insecto ingiera. Hay cinco (p. 154) anillos blancos muy carac-
terfsticos en las patas traseras; corresponden a las articulaciones
del tarso, metatarso y de la tibia, donde a veces existe otra,
sexta, mancha blanca. En las patas del medio y en las delanteras
hay dos 6 tres pintas blancas. En los lados del torax hay ocho
6 diez puntos blancos redondos, y en la parte antero-superior
del mismo torax se ve un conjunto de lineas blancas que figura
bastante bien una lira de dos cuerdas, trazada en bianco sobre
fondo negro. Los palpos y las antenas tambien llevan pintas
blancas. Algunas de esas pintas con el tiempo y el roce suelen
borrarse, pero es raro que dejen de persistir las mas caracteristicas.
Las alas del C. mosquito, cuya nervadura excuso describir aqui,
no presentan las manchas senaladas en el Culex annulatus de
Europa, y son tan cortas que cerradas dejan descubierto el ul-
timo segmento del cuerpo. Parece inutil advertir que, para obser-
var los caracteres que dejo senalados, es in dispensable emplear
un vidrio de aumento; las lentes aplanaticas, de dos y media
a tres pulgadas de foco, me han parecido las mas convenientes.
El macho de ambas especies se reconoce facilmente por sus
antenas plumosas, que le dan el aspecto de llevar bigote, y por
su trompa que parece trifida, debido a que los palpos son tan
largos como ella, y despues de quedar aplicados contra ella en
^6 Medical Classics
Jos dos tercios superiotes, se separan antes de liegar a la punta,
contrastando notablemente con la tronipa lisa de la hembra,
cuyos palpos no llegan sino & una sexta parte de su longitud.
Las dos especies de mosquito no salen a las mismas horas:
al zancudo corresponde la noche y ai C. mosquito el dia. De-
seoso de averiguar el motivo de ese reparto del dia y de la noche
entre las dos especies, pense que el zancudo, a pesar de sus dimen-
siones mayores y su aspecto mas robusto, quiza no estuviese
organizado para resistir el calor del sol de nuestro verano, mien-
tras que el mosquito con su integumento reforzado podria resis-
tirio mejor. Hice, pues, el siguiente experimento: el 9 de Junio,
a las 12 del dia, expuse a ios rayos directos del sol los dos termo-
metros de mi sicromentro; al (p. 155) cabo de media hora el
seco marcaba 42° 25 y el humedo 31 0 75; coloque entonces, en
lugar del instrumento, un tubo donde estaba aprisionado un zan-
cudo, cogido ya desde cinco dias, pero vivo y agil tod avia, — a
los cinco minutos estaba muerto. Puse entonces otro tubo igual
con un Culex mosquito, y despues de dejarlo quince minutos lo
encontre sin dano alguno, y siguio vivo durante veinte y cuatro
horas mas dentro de su tubo.
Sabido es que sola la hembra del mosquito es la que pica y
chupa la sangre, mientras que el macho se sustenta con jugos
vegetales, principalmente los dulces; pero hasta ahora no he visto
senalado en los au tores que han escrito sobre el asunto la circuns-
tancia de que tampoco la hembra pica antes de haber sido fecun-
dada por el macho. Esto, al menos, es lo que parece deducirse
de los experimentos siguientes:
Una hembra del C. mosquito, cogida al salir de la ninfa y
conservada dos y tres dias viva, en todo ese tiempo no se la
puede hacer picar. Varias veces he repetido este experimento y
siempre el resultado ha sido negative).
Las hembras aprisionadas en el acto de la fecundacion, ai sepa-
rate del macho pican en seguida y se llenan de sangre.
. T 1 T 1 ’ casi todas Ias hembras cogidas despues de haberse sa-
cia o e sangre, al cabo de algunos dias ponen huevos, mientras
que las fecundadas que no llegan a chupar la sangre mueren sin
El Mosquito 577
No es, por consiguiente, para su propio sustento que la
hembra del mosquito se muestra avida de sangre viva; y, en
efecto, no se concebirfa como, para sustentar un cuerpo tan dimi-
nutOj habria de necesitarse cantidad tan enorme de un alimento
tan rico como la sangre pura. Era, pues, forzoso admitir que
la sangre ingerida estaria destinada a otros fines, relacionados
con la propagation de la especie. Me inclino a suponer, como la
mas natural de mis hipotesis, que la influencia de la sangre es
debida a su temperatura; porque asi se comprende que si la madu-
racion de los ovulos contenidos en los ovarios del mosquito
hembra requiriese una temperatura de (p. 156) 37°C., esta, en
las condiciones meteorologicas de nuestra Isla, dificilmente podria
obtenerse con tanta seguridad y certeza como por el medio em-
pleado por el mosquito, ingiriendo un volumen de sangre consi-
derable de la temperatura necesaria, y, quiza, alguna vez con-
venga al mosquito elegir para sus fines algun febricitante cuya
sangre de 39 0 a 40° active mas aun el momento de la aovacion.
Asi tambien se comprende por que el zancudo y otros mosquitos
grandes pueden absorber en una sola vez toda la sangre necesaria
para madurar con su calor todos los aoo a 350 huevos que han de
poner y efectivamente ponen en una sola postura; mientras que
las especies mas pequenas, como el C. mosquito, necesitan llenarse
varias veces de sangre para empezar a poner y, por lo regular,
hacen la ovacion en dos 6 tres sesiones.
Una vez que el mosquito hembra se ha saciado de sangre em-
plea dos, tres y hasta cuatro dias, segun las especies, en digerirla;
durante cuyo tiempo, escondida de las miradas indiscretas, se
pasa horas enteras en unas operaciones curiosas que Reaumur no
supo explicarse, porque solo las observo en el estado de libertad.
Aprisionadas en tubos de vidrio, es fac'd cerciorarse de que esos
movimientos consisten en embarrarse todo el cuerpo con una
secrecion viscosa que el mosquito recoge de la extremidad del
ano con sus patas traseras y se unta con ellas todo el cuerpo:
cada pata por separado, el abdomen, las alas, el torax, la cabeza
y hasta la misma trompa. Como me ha sugerido nuestro dis-
tinguido academico,/flc; 7 f princeps entre los naturalistas cubanos,
D. Felipe Poey, esta operacion es probable que tenga por objeto
578 Medical Classics
hacer impermeable a la hembra del mosquito para cuando vaya
a poner sus huevos sobre el agua. Tambien durante la digestion
de la sangre ingerida depone el mosquito particulas sanguino-
lentas, que tienen la facultad de disolverse con extraordinaria
facilidad en el agua, aun despues de haber permanecido secas
durante varios meses. Esto se debe sin duda a la combinacion
de la sangre con la saliva que el insecto vierte en la herida,
destinada segun opinion general, a dar mayor fluidez a la sangre
que esta (p. 157) chupando. Por lo regular, despues de haber
ingerido toda la sangre que corresponde a una picada no inter-
rumpida, el mosquito no vuelve a picar, antes al contrario, evita
posarse sobre la piel desnuda (sin duda porque le desagrada en-
tonces el calor), hasta haber digerido toda la sangre. Este es el
momento de la aovacion en el zancudo.
No repetire la description ya clasica de Reaumur, en que tan
graficamente explica el modo como la hembra del mosquito de
Europa forma su botecillo tan elegante de huevos y lo echa al
agua. Parece ser la misma operation la que ejecuta el zancudo
de Cuba. Pero habiendo observado que las hembras zancudas,
despues de poner su botecillo de huevos, suelen quedar muertas
sobre el agua, he llegado a creer que los cadaveres que Reaumur
solia considerar como tantas recien nacidas naufagadas al des-
prenderse de la ninfa, en realidad serfan los de las madres que se
dejan morir al lado de sus huevos, quiza para contribuir a la
alimentacion futura de las larvas.
Las tres operaciones sucesivas: fecundacion, picada y aovacion
o postura de huevos, constituyen un ciclo ineludible dentro del
cual habra de girarse la existencia del mosquito. La primera de
estas^ funciones, la fecundacion, es probable que, como en los
demas insectos, tenga lugar una sola vez, bastando una sola
impregnation del saco seminal por el semen del macho, para que
en lo sucesivo queden fecundados todos los huevos que atraviesen
la parte correspondiente de los oviductos. En la abeja cubana,
ya nos !o ha dicho D. Felipe Poey, basta una sola fecundacion
e a embra por el macho para que resulten fecundados todos
los huevos que a millares debe poner aquella, durante los dos
o tres anos que durara su existencia. Con las hembras del
El Mosquito 579
genero Culex hasta ahora estudiadas, no hay lugar de poner a
prueba esa fecundacion prolongada, puesto que la aovacion se
efectua en ellas en una sola vez; pero no sucede as! con las
hembras del C. mosquito. Estas ponen sus huevos aislados 6
en hileras de nueve a quince, separados 6 juntos, unas veces
sobre el agua, otras sobre los cuerpos adyacentes bastante cerca
del nivel para que una (p. 158) pequena elevacion permita al
agua banarlos. Cualquiera que sea el valor de la hipotesis que
he propuesto, para explicar la necesidad que tiene el C. mosquito
de picar varias veces y llenarse otras tantas de sangre viva, a
fin de llevar a cabo la postura de todos sus huevos, 16 cierto es
que las hembras de esa especie siempre se hallan en disposicion
de volver a picar despues que han digerido la sangre que hablan
chupado en la primera picada. En el caso de una de esas
hembras cogida en el mes de Enero del corriente ano, ella pico
doce veces y tres veces efectuo la aovacion durante los 31 dias
que vivio; habiendo ido a morir en los Estados Unidos, donde a
la sazon la temperatura exterior estaba por debajo de o°C.
Con el C. cubensis 6 el zancudo, por lo contrario, no he
logrado nunca una segunda picada con las hembras aprisio-
nadas, hubiesen 6 no puesto sus huevos. Posible es, sin em-
bargo, que, en estado de libertad, ellas necesiten a veces varias
picadas sucesivas antes de proceder a la aovacion; si he obser-
vado alguna vez que venian a picarme, teniendo ya el vientre
ocupado por alguna sangre; pero he creido que esto resultara
por haber sido interrumpida la picada anterior antes que el
insecto hubiese ingerido toda la sangre que le correspondiera.
Es evidente que bajo el punto de vista en que estoy consi-
derando el mosquito, la especie C. mosquito se encuentra en
condiciones admirables de aptitud para llevar de un individuo
a otro una enfermedad que fuese transmisible por medio de la
sangre, toda vez que tiene multiples ocasiones de chupar sangre
de distintas procedencias y tambien deinficionaradistintos indi-
viduos; aumentando notablemente las probabilidades de quesu
picada pueda reunir las coincidencias necesarias para que se
realice la trasmision. Por otro lado, el C. cubensis, al absorber
por su trompa mayor cantidad de sangre virulenta, debera
5 So
Medical Classics
quedar mas impregnada y en condicion de producir una inocu-
lacion mas grave, maxime si esta se efectua a los pocos instantes
de haber salido las lancetas de la zancuda del vaso capilar de un
enfermo, como habra de suceder cuando su primera picada ha
sido interrumpida. Aqui, pues, (p. 159) sera mas grave la in-
feccion, pero menos probable su ocurrencia.
No es posible, empero, comprender las extraordinarias facili-
dades que la picada del mosquito ofrece para la inoculacion de
cualesquiera particular contagiosas que la sangre pudiese con-
tener, sin antes hacerse cargo de la conformacion y estructura
del aparato que la hembra del mosquito emplea para picar y
chupar la sangre. Lo que se ve de la trompa del mosquito en
condiciones normales es la vaina, resultado de la transformacion
del labio inferior: ella nace por un pediculo implantado en la
base de la cabeza, debajo de las otras piezas orales, esta hen-
dida en su parte superior y en toda su longitud hasta llegar a
un botoncito terminal, que considero analogo a un par de
palpos labiales, y de cuya extremidad salen las puntas de las
otras piezas que contiene. La vaina del C. mosquito, a cuya
especie be limitado mis observaciones, mide dos y medio mili-
metros de largo; una linea francesa, dice Reaumur que tenia
la trompa de la especie que el observo: y como quiera que
nuestro mosquito a veces mete sus lancetas hasta muy cerca de
su insercion, se vera cuan facilmente habra de alcanzar cualquier
vaso que se encuentre a menos de un quinto de centimetro de
la superficie cutanea. Dentro de la vaina existen dos tubos que
parecen sueltos en el fondo de su concavidad, donde los he
visto algo tortuosos; los dos se reunen en un tronco comun,
el cual ocupa la concavidad del pediculo de la vaina. Creo
que por esos tubos vierta el mosquito la saliva acre e irritante
que ocasiona el escozor de la picada, y destinada, segun creen
os naturalistas, a hacer mas fluida la sangre que ha de correr
por e si on. En el interior de la vaina se encuentran cinco
piezas: una, la principal, es impar, procedente del labro 6 labio
superior de consistencia cdrnea y prolongada en forma de
en P tnT 0I J darr ! ent ; e a canalado y abierto por su parte superior,
a su ongitud, hasta terminar en una punta como la de un
El Mosquito 581
limpia-dientes que se hibiese cortado en un canon de pluma
largo y angosto. Esta pieza es rlgida y en toda su superficie
externa presenta un labrado (p. 160) muy curioso, como si sobre
ella estuviese aplicada una red cuyas mallas, en relieve, formaran
unos paralelogramos pequenos con los angulos mas agudos
dirigidos en el sentido longitudinal. Dentro de esas mallas
innumerables facilmente podrian alojarse particulas de la sangre
chupada. Las otras cuatro piezas consisten en dos pares de
lancetas flexibles, correspondientes a las dos mandibulas y a las
maxilas e implantadas a la raiz de los dos palpos maxilares que
se ven de cada lado de la trompa. La estructura de estas dos
clases de lancetas es enteramente distinta: la lanceta mandi-
bular consiste en una pieza acanalada y con tendencia a con-
servar su forma encorvada; su cara externa es convexa y pre-
senta en toda su extension unas crestas transversales, paralelas
y compuestas, segun creo, de unos dientes. Tambien los bordes
de su hendidura longitudinal presentan unos dientes de filo muy
acerado; la punta de esta lanceta es encorvada y convexa, pre-
sentando dientes en sus bordes libres hasta la misma extremidad,
cuya sutileza y fuerza deben ser muy considerables, a juzgar por
su aspecto. Las lancetas maxilares, cuyo orfgen se encuentra
mas abajo del de las mandibulares, tienen la forma de una cinta
cuyos bordes estuvieran doblados hacia adentro, como un dobla-
dillo, y cuyo borde libre, as! doblado, estuviese armado de una
franja de dientes muy finos y largos: esta lanceta, en su con-
junto, se asemeja a las hojas largas y angostas de ciertas yerbas,
y tambien por su punta ancha, de doble filo, reforzada en el
medio por una nervura longitudinal. Todas estas piezas se
amoldan sobre el espolon del labro de tal manera, que al separar
la vaina, antes de la disociacion de las lancetas, parece im-
posible que la varilla redonda u ovalada con su punta unica,
aguda y afilada que se tiene a la vista pueda ser el conjunto
de las cinco piezas que acabo de describir.
La operacion de la picada comienza por la exploracion que hace
el mosquito, tentando la piel con la punta de su trompa hasta
encontrar un lugar conveniente y entonces se planta con decision
sobre sus seis patas (a veces mantiene las dos traseras (p. 161)
5 82
Medical Classics
levantadas), el torax fuertemente inclinado hacia abajo, la ca-
beza y la trompa casi verticales. En seguida, con la simple vista
6 mejor con un vidrio de aumento, se ve la vaina encorvarse
hacia atras, en su parte superior, y gradualmente doblarse en
forma de una < horizontal, cuyas ramas van gradualmente
aproximandose a medida que las lancetas penetran en la piel.
Estas aparecen en forma de un alambre muy sutil tendido entre
las extremidades de la < figurada por la vaina y se las ve moverse
al par que los palpos maxilares, hasta que, habiendo penetrado
en la luz de algun vaso capilar, el insecto se inmoviliza mientras
se llena, al parecer sin ningun esfuerzo de su parte, con la sangre
roja y caliente de su victima. Durante esta operacion se siente
a veces un escozor instantaneo, debido a la saliva que el mosquito
vierte en la herida por la extremidad de la vaina, cuyo boton se
halla cogido en la cisura. El vientre se abulta y la sangre se
hace visible al traves de sus paredes laterales transparentes.
Esta operacion por lo regular dura varios minutos y yo la he
visto prolongarse hasta siete.
Sabido es que los mosquitos, aunque nunca desaparecen del
todo en la Habana, tienen sin embargo epocas estacionales en
que son mucho mas numerosos que en otras. Su numero me ha
parecido aumentar progresivamente desde Abril 6 Mayo hasta
Agosto, para de alii decrecer gradualmente hasta Febrero y
Marzo. Pero hay un punto relativo al estudio que venimos ha-
ciendo, que no es posible desatender por razon de las numerosas
aplicaciones que puede tener en ciertos casos, hasta ahora inex-
plicados, de reproduccion de epidemias de fiebre amarilla, sin
nueva importacion, en localidades hasta entonces consideradas
inmunes. Me refiero a la hibernacion del mosquito, fenomeno
que no se observa en nuestro clima, al menos en todas sus fases,
pero que constituye, segun las mas autorizadas opiniones, ei modo
regular de propagarse la especie en los climas frios. Dice en
e ecto e r. Taschenberg: las hembras fecundadas de la ultima
generacion ibernan en los mas diversos escondrijos, principal-
men te en as cuevas de las (p. 162.) casas, para luego propagar
su especie en la siguiente primavera.”
u cuanto a las condiciones que favorecen el desarrollo de los
El Mosquito 583
mosquitos citare el calor, la humedad, la presencia de aguas estan-
cadas, las localidades bajas y oscuras, la ausencia de viento y la
estacion del verano; pero no estara de mas recordar la observation
de Humboldt, de que la abundancia de los mosquitos no siempre
obedece a condiciones meteorologicas ni topograficas deter-
minables.
He hablado ya de la dificultad que el mosquito, por motivo de
sus alas relativamente pequenas, necesariamente ha de experi-
mentar para elevarse en el aire despues de haberse saciado de
sangre. La misma causa impedira tambien que el mosquito se
aparte mucho del lugar donde haya efectuado su ultima picada y,
en general, que pueda mantenerse mucho tiempo en el aire, ni
trasladarse. a distancias considerables, sin posarse. Mas esto no
se opone a que, escondido entre la ropa, en un sombrero, en una
maleta de viaje, etc., el mosquito, despues de una picada reciente,
pueda ser trasportado a grandes distancias llevando quiza, en sus
lancetas, el germen inoculable de la enfermedad.
En fin, debese tener en cuenta las preferencias que los mos-
quitos manifiestan hacia ciertas razas e individuos, notandose que
la menos atormentada parece ser la africana, y los individuos mas
perseguidos por ellos los de razas del norte recien venidos a las
regiones tropicales de America. Parece verosimil que esto obe-
dezca al grado de espesor de la piel y a las condiciones en que se
efectua la circulacion capilar cutanea, puesto que esas circun-
stancias han de influir en la facilidad con que el mosquito hembra
podra procurarse la sangre que necesita para completar el ciclo
de su existencia.
Hecha esta larga, pero necesaria explication de los habitos de
nuestros mosquitos de Cuba y del C. mosquito en particular,
veamos ide que medios podrfa valerse el mosquito para comu-
nicar la fiebre amarilla, si esta enfermedad fuese realmente trans-
misible por la inoculation de la sangre? Lo mas (p. 163) natural,
al hacernos esta pregunta, es pensar en la sangre virulenta que el
mosquito ha chupado a un enfermo de fiebre amarilla y que
puede ascendar a cinco y hasta 7 u 8 milimetros cubicos, los
mismos que, si el mosquito muriese antes de haberlos digerido,
quedanan en excelentes condiciones para conservar durante largo
584-
Medical Classics
tiempo sus propiedades infectantes. Tambien podra pensarse,
sin duda, en la misma sangre que, en forma de excremento, de-
ponen los mosquitos en las aguas potables y otras, y que bien
pudiera llevar la infeccion si esta fuese susceptible de introducirse
por la boca. Pero los experimentos de Ffirth y ciertas considera-
ciones directamente enlazadas con mi modo de apreciar la pato-
genia de la fiebre amarilla no me permidan detenerme en nin-
guno de esos modos de propagacion. Yoy a decir por que.
Cuando la Comision Norte Americana de Fiebre Amarilla al
despedirse de nosotros, ahora dos anos, nos dejo su valiosa colec-
cion de fotograffas de las preparaciones microscopicas hechas por
nuestro socio corresponsal el Dr. Sternberg, lo que mas llamo mi
atencion fue la circunstancia alii demostrada de que los globulos
rojos de la sangre salen enteros en las hemorragias de la fiebre
amarilla; y como quiera que esas hemorragias se efectuan a veces
sin rotura perceptible de los vasos, era forzosa la deduccion de
que, siendo ese sintoma el caracter clinico mas esencial de la
enfermedad, habria que buscarse la lesion principal en el endotelio
vascular. Pensando luego en las circunstancias de que la fiebre
amarilla es transmisible, que no ataca sino una vez a un mismo
mdividuo, y que siempre presenta, en sus manifestaciones, un
orden regular como el de las fiebres eruptivas, llegue a formarme
una hipotesis en la que consideraba esa enfermedad como una
fiebre eruptiva cuya erupcion se hiciese en el endotelio vascular.
El primer penodo seria el de la fiebre de invasion, la remision
coincidiria con el penodo de erupcion, y el tercer periodo seria el
de descamacion. Si esta se efectua en buenas condiciones, el
enfermo solo presentara los indicios de una filtracion exagerada
de algunos elementos de la sangre al traves del endotelio nuevo:
(p. 164) si en malas el endotelio, mal repuesto, no podra impedir
la salida de los elementos figurados de la sangre, vendran las
emorragias^ pasivas y habra peligro inminento para el paciente.
n fin, asimilando esta enfermedad a la viruela y a la vacuna, me
1 u ^ U£ * n . ocu ^ ar l a habria que ir a buscar la materia inocu-
a e en e interior de los vasos de un enfermo de fiebre amarilla
a tai ^ £n ^ n *- er * or u n vaso sanguineo de otro indi-
uo en aptitud de recibir la inoculacion. Condiciones todas,
El Mosquito 585
que el mosquito realiza admirablemente con su picada y que seria
punto menos que imposible a nuestras manos imitar, con los
instrumentos comparativamente toscos y groseros que puedc pro-
ducir el mas habil de nuestros artesanos.
Tres condiciones seran pues necesarias para que la fiebre ama-
rilla se propague: 1. Existencia de un enfermo de fiebre amarilla,
en cuyos capilares el mosquito pueda clavar sus lancetas e im-
pregnarlas de particulas virulentas, en el pariodo adecuado de la
enfermedad; a. Prolongacion de la vida del mosquito entre la
picada hecha en el enfermo y la que deba reproducir la enfer-
medad; y 3. Coincidencia de que sea un sujeto apto para contraer
la enfermedad alguno de los que el mismo mosquito vaya a picar
despues.
La primera de estas condiciones, desde que el Dr. D. Ambrosio
G. del Valle ha comenzado a publicar sus valiosas tablas mortuo-
rias, puede asegurarse que jamas ha dejado de hallarse realizada
en la Habana; en cuanto a la y la 3“., es evidente que las
probabilidades de que resulten cumplicas dependeran de la
abundancia de los mosquitos y del numero de individuos sus-
ceptibles de recibir la inoculacion que se encuentren en la locali-
dad. Creo que, efectivamente, en la Habana han coincidido
siempre las tres condiciones senaladas los anos en que la fiebre
amarilla ha hecho sus mayores estragos.
Tal es mi teoria, senores, y en verdad ella ha venido a robuste-
cerse singularmente con las numerosas coincidencias historicas,
geograficas, etnologicas y meteorologicas que ocurren entre los
datos que se refieren al mosquito y los que tenemos (p. 165)
acerca de la fiebre amarilla, y tambien con la circunstancia de
que podemos con su auxilio explicar circunstancias hasta ahora
inexplicables por las teorias existentes. La fiebre amarilla no
fue conocida en la raza blanca hasta despues del descubrimiento
de America, y segun Humboldt es opinion tradicional en Vera-
cruz, que alii ha existido esa enfermedad desde que vinieron a
sus playas los primeros exploradores espanoles. AIK tambien
hemos visto que los espanoles desde su primera venida senalaron
la presencia de mosquitos, y, con mas insistencia que en ningun
otro lugar de America, en los mismos arenales de San Juan de
^86 Medical Classics
Ulua. Las razas mas expuestas a padecer la fiebre amarilla son
tambien las que mas sufren de las picadas de los mosquitos. Las
condicioncs meteorologicas que mas favorecen el desarrollo de
esa fiebre son las mismas que acrecientan el numero de los mos-
quitos: en abono de cuyo aserto puedo citar varias epidemias
parciales respecto de las cuales se afirma, bajo la garantia de
medicos competentes, que durante la prevalencia de la fiebre
amarilla los mosquitos habian sido mucho mas numerosos que en
epocas pasadas, haciendose constar, en un caso, que los mosquitos
eran de especie distinta de las que allx solian observarse, y que
llevaban unas manchas grises en el cuerpo. Respecto a la topo-
grafia de la fiebre amarilla, el mismo Humboldt, que senala las
alturas hasta donde suelen llegar los mosquitos, en otro lugar
menciona los limites de elevacion hasta donde suele propagarse
la fiebre amarilla. En fin, en el caso muy notorio del vapor de
los Estados Unidos “Plymouth,” en que 1 casos de fiebre amarilla
se desarrollaron en alta mar despues de haber sido desinfectado
y congelado el buque durante todo el invierno, y de haber trans-
currido cuatro meses desde el ultimo caso observado abordo, en el
mes de Noviembre anterior, se explica perfectamente por la hiber-
nation de aquellos mosquitos que hubiesen picado a los anteriores
casos de vomito y luego, encontrandose otra vez bajo una tem-
peratura tropical, volvieron a salir de su letargo y picaron a dos
de los nuevos tripulantes del buque.
(p. 1 66 ) Apoyado pues en esas razones, determine someter a
prueba experimental mi teoria, y despues de obtener las debidas
autorizaciones, procedi de la manera siguiente.
El dia i2> de Junio proximo pasado, lleve a la casa de salud de
Garcini un mosquito cogido antes de que hubiera picado, y le
hice picar y llenarse de sangre en el brazo de un enfermo, D.
Camilo Anca, que se hallaba en el quinto dia de fiebre amarilla,
perfectamente caracterizada, y de cuya enfermedad fallecio dos
dias despues. Habiendo lu6go elegido A F. B, uno de los veinte
mdividuos sanos no aclimatados a esa enfermedad, que se encuen-
tran actualmente sometidos a mi observation, le hice picar, el
3° e Jumo, por el mismo mosquito. Teniendo entonces en
uenta que a incubacion de la fiebre amarilla, comprobada en
a gunos casos especiales, varia de uno a quince dias,— segui ob-
El Mosquito 587
servando al citado F. B. — El dia 9 empezd a sentirse mal, y cl
1 4 entro en el Hospital con una fiebre amarilla benigna, pcro pcr-
fectamente caracterizada por el ictero y la presencia dc albumina
en la orina, la cual persistio desde el tercero hasta el noveno dia.
El dia 16 de Julio hice picar en la misma casa de salud dc
Garcini un caso de fiebre amarilla grave, Don Domingo Rodriguez,
en tercero 6 cuarto dia de enfermedad. El dia 20 me hice picar &
mi mismo por el mismo mosquito, y en fin, el 22, hice picar a
A. L. C., otro de los veinte observados. A los cinco dias entr6
en el hospital con fiebre, dolores fuertes de cabeza y de cintura 6
inyeccion de la cara; duraron tres dias estos sintomas, entrando
en convalescencia el individuo sin haber presentado ictero ni albu-
minuria. Fue diagnosticado de fiebre amarilla abortiva por el
facultativo de asistencia.
El dia 29 de Julio hice picar por un mosquito k D. L. R. que
se hallaba gravemente atacado de fiebre amarilla en la casa de
salud de Garcini en tercer dia de la enfermedad. El 31 hice
picar por el mismo mosquito a D. L. F., otro de los veinte indivi-
duos de mi observacion. El 5 de Agosto & las dos de la madru-
gada fue invadido de los sintomas de una fiebre (p. 167) amarilla
ligera; presento luego algun ictero, pero creo que no lleg6 a
presentar ninguna albumina; en todo caso su esfermedad fue cali-
ficada de fiebre amarilla abortiva.
En fin, el 31 de Julio hice picar por otro mosquito al mismo
D. L. R. enfermo de fiebre amarilla de la casa de salud dc Gar-
cini, en quinto dia ya de la enfermedad, de la cual fallecio al dia
siguiente. El 2 de Agosto hice picar por el mismo mosquito a
D. G. B., otro de mis veinte observados. Hasta ahora esta ul-
tima inoculacion no ha producido resultado; pero como quiera que
no han transcurrido sino doce dias, todavia se encuentra dentro
de los limites de la incubation. (1)
(1) Estc individuo, D. G. B., sc presento cl dia 17 dc Agosto a! rcconocimicnto, mani-
festando que desde unos 6 dias venia padeciendo dolores de cabeza, inapeteneia y malcstar
general. E! 24 le encontr£ con alguna fiebre (Pulso 100; temperatura 38°^), v manifcst6
haber tenido fiebre mas alta la vispera y el mismo dia, por la manana. No pas6, empero,
de una fiebre muy ligera, puesto que cl enfermo no tuvo que darsc dc baja, ni exigio medi-
cadon alguna. Ceso la fiebre, pero los dolores dc cabeza continuaron algunos dias mas.
Otro individuo, I. C,, dc los veinte, fu£ picado cl dia 15 dc Agosto, por un mosquito
que, dos dias antes sc habia llenado en cl brazo dc un enfermo del Hospital Militar, en
5 8 8 Medical Classics
Eebo advertir que los individuos que acabo de citar son los
unicos a quienes he inoculado por el mosquito, de la manera
indicada, y que desde el ii de Junio hasta ahora (en el termino
de siete semanas) no han ocurrido entre mis veinte observados
mas casos de fiebre amarilla confirmada, ni tampoco de forma
abortiva, que los tres primeros inoculados.
Estas pruebas son ciertamente favorables a mi teoria, pero no
quiero incurrir en la exageracion de considerar ya plenamente
probado lo que aun no lo esta, por mas que sean ya muchas las
probabilidades que puedo invocar en mi favor. Comprendo
demasiado, que se necesita nada menos que una demostracion
irrefutable para que sea generalmente aceptada una teoria que
discrepa tan esencialmente de las ideas hasta ahora propagadas
acerca de la fiebre amarilla; mas, entretanto se proporcionan los
datos de que aun carecemos, seame permitido (p. 168) resumir
en las siguientes conclusiones los puntos mas esenciales que he
tratado de demostrar.
CONCLUSIONES.
I s . Queda comprobado que el C. mosquito pica, por lo regular,
varias veces en el curso de su existencia, no tan s 61 o cuando su
primera picada ha sido accidentalmente interrumpida, sino tam-
bien cuando ha podido saciarse por completo, transcurriendo, en
este caso, dos 6 mas dias entre sus picadas.
a tt . Como quiera que la disposicion de las lancetas del mos-
quito se adaptan muy bien a retener particulas que se encuentren
suspendidas en los hquidos que el insecto ingiere, no puede ne-
garse la posibilidad de que un mosquito conserve en sus lancetas
particulas del virus contenido en una sangre enferma y con el
mismo inocule a las personas a quienes en lo sucesivo vaya a
pi car.
3 • La experimentacion directa para determinar si el mosquito
fermo hasra P arece *l ue cstc inoculado haya estado formalmente en-
por aviso verbal^ e&e ™ , re j * )• podido verle despues de la inoculacion, y s 61 o
r- ^ b tr;:r e d d : r-:; haUaba a,go enfe ™ ios ^ * ****
El Mosquito 589
puede transmitir la fiebre amarilla de la manera indicada, se ha
reducido a cinco tentativas de inoculacion, con una sola picada,
y estas dieron por resultado: un caso de fiebre amarilla benigna,
pero perfectamente caracterizada con albuminuria e ictero; dos
casos calificados de fiebre amarilla abortiva por los facultativos de
asistencia; y dos de fiebres effmeras ligeras, sin caracter definido
(1). De lo cual se infiere que la inoculacion por una sola picada
no es suficiente para producir las formas graves de la fiebre
amarilla, debiendose aplazar el juicio respecto a la eficacia de la
inoculacion para cuando sea posible experimentar en condiciones
absolutamente decisivas, esto es, fuera de la zona epidemica.
4 a . Si llegase a comprobarse que la inoculacion por el mos-
quito no tan solo puede reproducir la fiebre amarilla, sino que
es el medio general por el cual la enfermedad se propaga, las
condiciones de existencia y de desarrollo de ese diptero expli-
carian las anomalias hasta ahora senaladas en la (p. 169) propa-
gacion de la fiebre amarilla y tendriamos en nuestras manos los
medios de evitar, por una parte, la extension de la enfermedad,
mientras que, por otra, podrian preservarse con una inoculacion
benigna los individuos que estuviesen en aptitud de padecerla.
Mi unica pretension es que se tome nota de mis observaciones
y que se deje a la experimentacion directa el cuidado de poner
en evidencia lo que hay de cierto en mis conceptos. Esto no
quiere decir, empero, que yo rehuya la discusion de las ideas que
he emitido; antes al contrario, tendre el mayor gusto en oir las
advertencias u objeciones que quisieren hacerme mis distinguidos
companeros.
Habana, 14 de Agosto de 1881.
Carlos Finlay.
( 1 ) Respecto de estos dos ultimos, v6ase la nota anterior.
The Mosquito Hypothetically
Considered as the Agent of Trans-
mission of Yellow Fever
Read before the Royal Academy of Medical, Physical and Natural
Sciences 1
Session of August 14th, 1881.
Published in Frcbajos Selectos del Dr. Carlos f. Finlay, Secretaria de Sanidad y
Beneficencia, Republica de Cuba, Habana, 1912, pp. 27-43
Mr. President , Gentlemen:
OME years ago I had the honor to submit to
your consideration the results of my alkali-
metric experiments, by which I think I have
definitely demonstrated the excessive alkalin-
ity which prevails in the atmosphere of Havana.
Some of the Members now present, may per-
haps remember the relations which I then attempted to establish
etween that peculiarity and the development of yellow fever
in u a * Much however has been done since that time, more
accurate data have been obtained, and the etiology of yellow
lever has been more methodically studied. In consequence
ereo ee convinced that any theory which attributes the
gin an propagation of yellow fever to atmospheric influences,
0 > miasmatic or meteorological conditions, to filth or to the neg-
genera ygienic precautions, must be considered as
y Raturalll * & Ae f"!t itt . de M{dicas > Fiskas
Farmaciutha de la Isla r C t 5 P' 4 ?‘ ^ lc * e a * so Revtstc de la AsoeiaciSn MSdico -
xsia ae Uit>a } January 1902, p. 273.
The Mosquito 591
utterly indefensible. I have, therefore, been obliged to abandon
my former ideas, and shall now endeavor to justify this change
in my opinions, submitting to your appreciation a new series of
experiments which I have undertaken for the purpose of dis-
covering the manner in which yellow fever is propagated.
In this paper I shall not concern myself with the nature or
form of the morbific cause of yellow fever, beyond postulating
the existence of a material, transportable substance, which may
be an amorphous virus, a vegetable or animal germ, a bacterium,
etc., but, at any rate, constitutes something tangible which re-
quires to be conveyed from the sick to the (p. 28) healthy before
the disease can be propagated. What I propose to consider is
the means by which the morbific cause of yellow fever is enabled
to part from the body of the patient and to be implanted into
that of a healthy person. The need of an external interven-
tion, apart from the disease itself, in order that the latter may be
transmitted is made apparent by numerous considerations;
some of them already pointed out by Humboldt and Benjamin
Rush since the beginning of this century, and now corroborated
by recent observations. Yellow fever, at times, will travel
across the Ocean to be propagated in distant ports presenting
climatic and topographic conditions very different from those of
the focus from which the infection has proceeded, while, at other
times, the disease seems unable to transmit itself outside of a very
limited zone, although the meteorology and topography beyond
that zone do not appear to differ very materially. Once the
need of an agent of transmission is admitted as the only means of
accounting for such anomalies, it is evident that all the conditions
which have hitherto been recognized essential for the propaga-
tion of the disease must be understood to act through their
influence upon the said agent. It seemed unlikely, therefore,
that this agent should be found among Micro or Zoophytes, for
those lowest orders of animal life are but little affected by such
meteorologic variations as are known to influence the develop-
ment of yellow fever. To satisfy that requisite it was necessary
to search for it amongst insects. On the other hand, the fact of
yellow fever being characterized both clinically and (according
2 Medical Classics
to recent findings) histologically, by lesions of the blood vessels
and by alterations of the physical and chemical conditions of the
blood, suggested that the insect which should convey the in-
fectious particles from the patient to the healthy should be looked
for among those which drive their sting into blood-vessels in
order to suck human blood. Finally, by reasons of other con-
siderations which need not be stated here, I came to think that
the mosquito might be the transmitter of yellow fever.
Such was the hypothesis which led me to undertake the ex-
perimental investigation which I shall here relate.
The application of the auxiliary sciences to Medicine often
demands such a minute acquaintance with the different branches
of human knowledge, that one cannot wonder at the length of
time which sometimes elapses before certain facts recorded in a
special branch can become available for purely medical inves-
tigations. This is particularly the case with regard to Natural
History; its acquisitions being the outcome of the direct observa-
tion of Nature must, as a rule, undergo a complete revision from
our own point of view before they can be turned to account in a
nosological investigation. It has thus happened that more than
a century after Reaumur had written his admirable Memoir on
the habits of mosquitoes, justly considered as a model of accurate
and keen observation, and which, (p. 29) from a general point of
view, appears to exhaust the subject, when, six months ago, I
recurred to that valuable source in search of data for the study
which I had undertaken, I could not obtain the ones which I
most needed. I was consequently obliged not only to go over
all the data given by Reaumur, in order to ascertain whether they
were also applicable to the Cuban mosquitoes, but to investigate
other details about which neither Reaumur nor any other
Naturalist had reason to be particularly interested. 1
, , , 6 trut . 0 remarks was well exemplified in the case of the mosquito which I
a egun to investigate in December 1880, as may be seen from the following notes copied
V 5 ^ ° ^ >a ? e f u P on 1vh 'ch I had jotted down all the information that I obtained
from the accomplished and well-known Cuban Naturalist D. Felipe Poev.
D 'PrVri-P anUai ? , Z f? r * ^' u ^ cx mosquito, Robineau Desvoidy, Cuban mosquito.
IS-’O and t\, Z} t0 ° * 1I . m *" rom < ” u ^ la t0 Paris some Cuban mosquitoes in 1817 or
1? '£ the > TCre riiere classified by Robineau Desvoidy.
pc oe) sa)s that, in the same manner as happens with other insects, the male
The Mosquito 593
Let us first recall the geographical distribution of mosquitoes.
They may be said, in general terms, to exist everywhere, except
at great altitudes above the sea-level. Many believe that the
dipterous insect with which we are concerned, the genus “Culex”,
constitutes a special torment of the tropical regions, while in
reality it is found in all latitudes. In the polar regions, the Lap-
landers, just as the inhabitants of the equinoctial regions of Amer-
ica, are prevented from taking their meals and from lying down
to sleep within their huts, unless they surround themselves with
an atmosphere of smoke in order to escape those pests. In the
open, those insects will fly into their mouths and nostrils, and,
notwithstanding the hardening of their skin during the previous
winters, they find it necessary to use veils steeped in fetid grease
and to anoint their bodies with cream or lard as a protection
against mosquitoes. In Canada, in Russia, in England, in
France, in Spain, all over Europe, in Siberia, China, the United
States, in North and South America, mosquitoes abound. In
Central Africa, a German explorer, Dr. Schwinfurst, was tor-
mented by a “spotty-legged” species whose description might
agree with that of the Cuban C. mosquito; and perhaps also the
species observed in Batavia by Arnold, as stated by Dr. Kirby,
who considers it as a non-descript variety, not unlike the C.
annulatus, but without any spots on its wings.
(p. 30) In the same geographical position, however, the mos-
quito shows a disposition to spread over continents rather than
to invade the islands, in accordance with Humboldt’s observation
that those insects are more abundant along the shores of large
dies after copulation, and the female after laying its eggs. That, in other respects, gen-
eration is accomplished under the same conditions as have been described regarding other
species.
That the eggs of the Cuban mosquito, deposited upon the water, are black.
That in his opinion, if some mosquitoes do live as long as eight days, it must be because
some accident has prevented the union of the male with the female.
The Culex annulatus has white rings upon its legs but its body is black; the C. mos-
quito, on the contrary (?), has silvery white plaques upon the last 5 articulations of its
3d pair of legs, 2. ill-defined ones upon the second pair, and two also on the other pair.
The abdomen is white underneath. The thorax, he is informed, presents a central longi-
tudinal line.
594
Medical Classics
rivers than upon the islets and that moscjuitoes are more trouble-
some close to the banks than in the centre of rivers. To this
circumstance may, perhaps, be due the silence of the first chron-
iclers of the Discovery of America about mosquitoes, with refer-
ence to the first voyages of Columbus. 1 I have not found any
mention of them with reference to the Antilles before 1538,
when Hernando de Soto’s soldiers having to cross a river near
Puerto de los Principes, were so severely bitten by mosquitoes
that large marks of blood appeared on their backs. To the com-
parative immunity of islands must probably be attributed the
following account given to Osten Sacken (quoted in Brehm,
V. IX, p. 446) by an American traveler. In 1823 mosquitoes
were unknown on the Hawaiian Isles; but between 1828 and 1830
an old ship from Mexico was abandoned close to the shores of
one of those islands. The inhabitants soon noticed around that
spot some blood-sucking insects previously unknown to them;
and the natives used to come in the evening to allow themselves
to be bitten by those extraordinary insects. Mosquitoes after-
wards multiplied and spread on those islands, developing into a
regular plague.
Although mosquitoes are found in all latitudes, their abun-
dance varies in different localities. Humboldt and Bonpland,
in their Travels in Equinoctial America wrote: “The annoyance
suffered from mosquitoes and “zancudos” in the torrid zone is
not so general as most people think. On the high plateaux more
than 400 toises (2500 feet) above the sea-level, and in very dry
plains, far from large rivers, such as Cumana and Calabozo,
gnats are not much more abundant than in the most populous
parts of Europe.” The influence of dryness and of a long dis-
tance from water-courses, pointed out by those travelers, is
easily understood, inasmuch as the larvae and pupae of the mos-
quitoes are aquatic, and the winged insect requires water for the
aying and hatching of its eggs. The impediment to their prop-
levels may consist in the exaggeration of the
1 cu ty which those insects must always experience in flying
Hisr 3 n!n/ S 8 m i 5 n ke ’ ^ ave s ' nce f° un d abundance of mosquitoes on the Island
Hispaniola specially mentioned in Herrera (Dt-cada I, Lib. V, cap. XI, p. ,79).
The Mosquito 595
upwards after they have filled themselves with blood; a difficulty
which will be much more marked in a species having such small
wings as those of the C. mosquito. The rarefaction of the atmos-
phere at those great heights necessarily increases that difficulty,
and, under those circumstances, the mosquito will instinctively
shun those localities. The above mentioned travelers also re-
late that a missionary priest, Bernardo Zea, had built himself a
room over a scaffolding of palm boards, and they (p. 31) used to
go there at night to dry their plants and to write their Diary,
adding: “The missionary had rightly observed that those in-
sects are more numerous in the lower strata of the atmosphere,
within 12 to 15 feet from the ground.” Further on they write:
“As one proceeds towards the plateau of the Andes, those in-
sects disappear and the air one breathes becomes pure. . . .at a
height of 200 toises (1500 feet) mosquitoes and zancudos are no
longer feared”.
Historically the mosquito is one of the insects most anciently
observed. Aristotle and Pliny refer to its proboscis which serves
both for piercing the skin and for sucking the blood. The Greek
historian Pausanias, according to Taschenberg, mentions the
city of Myus, in Asia Minor, situated on a bay which had for-
merly communicated with the sea but was afterwards cut off
from it; when the water in the lake which was thus formed ceased
to be salt, such a plague of mosquitoes was developed that the
inhabitants had to abandon the city and betook themselves to
Miletus. So also in the Decades of Hereera, we read that Juan
Grijalva when he first discovered the coast of New Spain (Mex-
ico), in 1518, landed with his men on an islet which he named
San Juan de Ulua, and they had to build their huts “at the top
of the highest sand-mounds which they could find in order to
avoid the importunity of mosquitoes.” Seven days later, Bernal
Diez del Castillo had to seek protection in some Indian places of
worship, “unable to stand the mosquitoes.” -Finally, in 1519,
on the same spot where Veracruz now stands, according to Her-
rera “the long-legged mosquitoes and the small ones which are
still worse used to worry the people who went with Cortes.”
I have observed two kinds of mosquitoes in Havana since
IVtcdiCcil (3l3.ssics
December last, when I began to study those insects. One spe-
cies is large, of a yellowish colour, with thin, long legs, and with-
out any particular markings; I suppose it must be the identical
zancudo which worried Cortes men on the sandy plains of San
Juan de Ulua in 1519, and the same which La Sagra describes as
the Cidex Cubensis. The length of its body, measured from the
root of the proboscis to the anal extremity, varies between 5 and
7 millimetres. This species comes out exclusively at night,
generally between 9 and 10 o’clock, and pursues its annoying
evolutions until daybreak. All the specimens which I have found
inside of mosquito-nets (in the morning) have belonged to that
species; and they remain part of the day in that position digesting
the blood which they have sucked. The other species is the
Culex mosquito, specimens of which were taken to Paris by the
distinguished Cuban Naturalist, Felipe Poey, in 1817 or 1820,
and were there classified by M. Robineau Desvoidy under that
name. I have noticed two varieties of this species: one large,
with a slight, graceful figure, vigorous, of a dark gray color,
somewhat smaller than the C. Cubensis; the other only measures
from 4 to 4^ millimetres. I have (p. 32) not sought for particular
differential characters between these two varieties of the same
species, their respective size sufficing for my present object.
Both varieties of the C. mosquito present the following distinc-
tive characters: the body is dark colored, sometimes almost black
or steel-colored; the ventral segments of the abdomen as well as
the dorsal ones appear strengthened by an outer layer, with
white rings corresponding to the inter-spaces, though sometimes
(on the ventral side) the segments are whitish and the inter-
spaces are dark. On each side of the abdomen there are two
rows of pearly-white dots, between which, after feeding, a trans-
parent membrane stretches allowing the blood or other contents
of the distended stomach and intestine to be seen. Upon the
hind legs there are five very characteristic white rings, corre-
sponding to the articulations of the tarsus, metatarsus and tibia;
t e latter sometimes presenting a sixth white spot. The middle
and front legs present two or three white rings. Upon the sides
o t e t orax are seen 8 or 10 white dots or patches of irregular
The Mosquito 597
outline, and upon the antero-superior surface of the thorax a com-
bination of white lines on a dark background is seen resembling a
two-stringed lyre. The palps and the antennae also carry some
white marks. Some of the aforesaid markings are apt to be
effaced with age or by friction, but the most characteristic ones
very seldom disappear. The wings of the C. mosquito, the vena-
tion of which I shall not describe at presents, have no spots like
those of the European Culex annulatus; and its wings are so
short that, when closed, they leave the last segment of the body
uncovered. Of course, in order to observe the characters which
I have been describing it is necessary to use a magnifying glass;
aplanatic lenses of 2§ or 3 inches focus are very convenient for
that purpose.
The males of both species are readily recognized by their
feathery antennae, like a pair of mustachios, and by its three-
pronged proboscis due to the long palps which lie close to the
proboscis above, but stand out on each side near the point;
thereby showing a marked contrast with the smooth proboscis of
the female whose short palps barely cover the upper sixth of its
length.
The two species of mosquitoes to which I have referred do not
come out at the same hours: the zancudo comes out at night and
the C. mosquito in the daytime. This distribution of the day
and night between the two species made me think that the zan-
cudo, notwithstanding its larger size and more robust appearance,
might not be constituted to stand the heat of our summer sun-
shine. I tried, therefore, the following experiment. On the
9th of June, at noon, I exposed to the direct rays of the sun the
bulbs of my psychrometer; after half an hour the dry bulb marked
42°. 25 C. and the wet bulb 3i°.75- I then substituted in place
of the instrument a tube in which a zancudo had been confined
for 5 days, but continued (p. 33) lively and agile; after 5 minutes’
exposure the insect was dead. I then substituted another tube
containing a Culex mosquito, and after leaving it exposed to the
sun during 15 minutes it was still alive and continued to live
another 24 hours in its tube.
It is well known that only the female mosquitoes bite and suck
59 8 Medical Classics
blood, while the males feed on vegetable juices, principally the
sweet ones; but I have not found it mentioned in any author that
even the females never bite before having been fertilized. This,
at least, I infer from the following experiments.
A female C. mosquito, caught soon after breaking loose from
its pupa-case, and kept alive during three days, cannot be got to
bite during that space of time. I have several times repeated the
experiment and always with a negative result.
Female mosquitoes which are caught pairing bite and suck
blood readily very soon after they are parted.
Finally, those which are caught in the act of biting and sucking
blood, will as a rule, lay eggs after a few days, while the fertilized
females which have not been allowed to suck blood die without
every laying any ova.
We are thus led to infer that the craving of the female mosquito
for live blood is not meant to supply an indispensable article of
food. Indeed it seems improbable that for the nourishment of so
small a body, such a disproportionate quantity of rich blood be
needed. I have come to the conclusion that the sucking of blood
is intended for another object connected with the propagation of
the species. The likeliest hypothesis seems to be that the feed of
blood acts through the degree of heat which it procures. If,
for instance, the maturation of the ovules contained in the ovaries
of the mosquito demands a temperature of 37°C., the latter could
scarcely be obtained by any other means so readily as by the
insect filling itself with a fair amount of blood of that tempera-
ture; and sometimes it may be more convenient for the mosquito
to bite a patient attacked with fever, whose blood at 39 0 or 40°
may prove more efficacious in hastening the process of ovulation.
It will thus be understood why large insects like the zancudo are
able to absorb with a single bite the amount of blood required for
the maturation of all the zoo to 350 ova which they lay at one
sitting, while the smaller species, like the C. mosquito, have to
bite and fill themselves several times with blood before beginning
to a}, and generally require several sittings before all their ova
are laid.
After the female mosquito has filled itself with blood it requires
The Mosquito 599
two, three or four days, according to the species ( and the season
of the year) to complete the digestion of its feed; and, during that
time, remains out of sight spending hours in a curious perform-
ance the object (p. 34) of which Reaumur did not understand,
having only observed it in the open. When the insect is confined
in a glass tube, it is easy to see that the performance consists in
besmearing every part of its body with a secretion which is picked
up from the anal extremity with its hind legs and smeared succes-
sively upon the legs, the abdomen, the wings, the thorax, the
head and even the proboscis. As suggested by Felipe Poey,
facile princeps among our Cuban Naturalists, the object of this
operation is probably to make the mosquito water-proof before
it goes to the water to lay its eggs. During the digestion, the
mosquito also drops some bloody particles or excrement which
present the peculiarity of being extremely soluble in water, even
after being kept in a dry condition during several months. This
is probably due to the admixture of the blood with the saliva
poured out during the process of biting, and which is generally
believed to render the blood more fluid while it is being sucked by
the insect. As a rule after a complete, uninterrupted feed of
blood, the mosquito does not bite again, and even shuns the con-
tact of the bare skin (perhaps because the heat of it becomes at
that time disagreeable) until the digestion of the blood has been
completed. With the zancudo (night-mosquito) it is at that
time that its ova are laid.
I shall not reproduce the classical description given by Reau-
mur of the manner in which the female of a European species,
Culex pipiens, builds its tiny boat of eggs and floats it on the
water. The zancudo of Cuba goes through a similar performance;
but after having launched their little boat of eggs, they often
stretch themselves out to die upon the water, and I have won-
dered whether the dead insects which Reaumur attributes to new-
born ones which have been wrecked and drowned at the moment
of leaving their pupa-shell might not be the cadavers of mothers
who had died in order that their bodies should remain close to
the ova so as to contribute to the feeding of their progeny.
The three successive operations: fertilization, sucking of blood
6oo Medical Classics
and laying of eggs, constitute the most essential phases of the
mosquito’s existence. The first of these operations, as in most
other insects, probably, need not occur more than once in order
that the impregnated seminal sack of the female shall retain the
faculty of fertilizing all the ova which may thereafter traverse
its oviducts. In the Cuban bee, according to Felipe Poey, a
single fecundation by the male, suffices for all the thousands of
eggs which the female bee lays during the two or three years of
its life. With the females of the various species of the genus
Culex, which, till now, had been observed, there had been no
occasion to test whether such a prolonged fertilizing faculty ex-
isted, inasmuch as all their ova were laid at a single sitting; but
the case is different with the females of the Culex mosquito.
These lay their ova separately or in files of 9 to 15 either isolated
or in groups, sometimes upon the water (p. 35) or else upon solid
bodies not too far removed from the level of the water, so that a
moderate elevation of that level will allow the water to cover
them. My explanation about the need of several bites and feeds
of blood before the C. mosquito is able to lay all its ova, maybe
purely hypothetical; it is nevertheless a fact that the females of
that species are always ready to bite a second time after they
have digested all the blood which had been sucked at a previous
bite. A female C. mosquito, caught (in Havana) in January of
the present year, had bitten 12 times and laid eggs three times in
the course of the 31 days which it lived; its death having occurred
in New York where it was exposed to temperature below the
freezing point.
With the captive females of the C. Cubensis (C. Ptwgens), I
have never been able to obtain a second bite, whether it had or
had not laid its ova. Possibly, however, when at large they may
need to bite several times before laying; for I have occasionally
seen them come to bite my hand, with some blood already in
£ L stoIt | ac ^ 1 * This I have attributed to a previous bite which
had been interrupted before the insect had been able to draw its
mil allowance of blood.
Evidently, from the point of view which I am considering, the
u ex mosquito is admirably adapted to convey from one person
The Mosquito 601
to another a disease which happens to be transmissible through
the blood; since it has repeated opportunities of sucking blood
from different sources, and also of infecting different persons; so
that the probabilities that its bite may unite all the conditions
required for the transmission will thereby be greatly increased.
On the other hand, inasmuch as the C. Cubensis absorbs a larger
quantity of the infectious blood at each feed, its mouth-parts
may retain a larger amount of virus, and perhaps produce a graver
inoculation when it happens to attack a non-immune a few mo-
ments after having bitten the patient, its first bite having been
interrupted. In that case, a graver infection might result but the
chances of its occurring would be much less.
In order to understand the special facilities which the bite of
the C. mosquito affords for the inoculation of any infectious par-
ticles which should be contained in the blood, it is necessary to
have some idea of the disposition and structure of the apparatus
used by the female mosquito in its operation of stinging and of
sucking blood.
What is seen of the proboscis, under ordinary circumstances is
the sheath, which represents a modified nether lip. It arises
from a pedicle attached to the base of the head, below the other
mouthparts. It is slit along its upper border as far as the ter-
minal, conical button seen at its free end, and which, I believe, is
formed by two labial palps. From the extremity of this button
the other pieces constituting the sting are protruded (in the act of
stinging). The sheath of the C. mosquito, to (p. 36) which
species my observations have been limited, measures milli-
meters; that of the species observed by Reaumur measured ac-
cording to that author, one French line; and as our mosquito
oftentimes drives its sting nearly to its very root, it can readily
reach a blood-vessel at a depth not exceeding 1/5 of a centimetre.
In the interior of the sheath are two tubes, lying apparently
loose at the bottom of its concavity; I have observed them pre-
senting a tortuous direction, and uniting into a common trunk
within the concavity of the pedicle. I believe it is through these
tubes that the mosquito pours out the acrid saliva which causes
the burning sensation during its bite, and which, according to
6o 2 Medical Classics
naturalists, serves to render more fluid the blood which has to
run through the sucking apparatus.
Within the sheath are contained five pieces: the principal one
constitutes the labrum or upper-lip, it is of a horny consistence
and prolonged like a long spur, deeply grooved so as to form a
canal opening upwards 1 and ending in a point like that of a
tooth-pick cut out of a long slender quill. This piece is rigid and
presents on its outer surface a curious design as if covered with a
net whose meshes, in relief, form small parallelograms with acute
angles pointing longitudinally. Perhaps within those innumer-
able meshes might be lodged some particles of the blood sucked
by the insect. The other four pieces are paired, flexible setae,
two of them constituting the mandibles, and the others the max-
illae. The structure of the two pairs is very different in each.
The mandibles are concave inwardly, and have a tendency to
maintain a curvilinear direction; their outer side is convex and
presents transverse ridges ending on their free border in very
minute teeth. The point of the mandibles is curved and armed
to its very end with teeth which appear to be both sharp and
strong. The maxillae are inserted a little below the mandibles;
they present the appearance of a ribbon with its edges turned in
like a seam, armed with a fringe of long delicate teeth ; its general
aspect is that of a long narrow blade of grass, ending in a broad
double-edged point and strengthened by a longitudinal vein run-
ning all along its middle. All these setae adapt themselves upon
the stem of the labrum so closely that, after the sheath has been
removed and before the setae are dissociated, one would never
think that the round or oval rod, with its sharp, single point,
which comes into view is an assemblage of the five separate pieces
which I have been describing . 2
^This is a misprint. It should read "downwards.”
The above description was written under the impression that only 5 mouth parts
went to constitute the sting of the Culex mosquito, and of mosquitoes in general. Soon
a ter jnting this paper, however, I became aware of the existence of a sixth seta, in
accor ance with the statements of modern entomologists.— On closer observation too, I
tiv™ v ^ a< ^ ^“^bed 33 one of the mandibles, more properly applies to the
fore -f re 3 • ° Ut 1 e e ® stence vhich I was at that time ignorant. I append there-
fore a reproduction of a drawing which I made in 1 88a or 83 of the six mouth parts of the
The Mosquito 603
The mosquito commences its operation of stinging by tenta-
tively exploring the skin with the point of its proboscis until it
finds a suitable spot. It then takes a firm position upon its six
feet (sometimes the two hind legs are raised above its back),
the thorax is strongly bent down while the head and the proboscis
assume a vertical position. Next, with the naked eye or, better,
with the assistance of a magnifying glass, the sheath is seen to
bend backwards, at its upper part, gradually assuming the shape
of an horizontal < the two branches of which gradually come
closer together as the sting penetrates deeper into the skin. The
sting is then seen as a very slender wire stretching between the
extremities of the horizontal < figured by the sheath, and moving
up and down in unison with the maxillary palps, until a blood-
capillary has been reached. The insect remains motionless
while it fills itself, apparently without effort, with the red warm
blood of its victim. During the bite a sharp, instantaneous,
burning sensation is sometimes felt, owing to the saliva which the
mosquito instils into the wound through the end of the sheath,
the conical extremity of which remains caught between the edges
of the wound. The insect’s stomach becomes distended and the
blood is seen through the transparent lateral walls of its body.
Several minutes are generally required for the completion of the
operation; as long as seven in some cases which I have timed.
It is a well-known fact that, while mosquitoes are never wholly
absent (p. 38) from Havana, they are much more abundant at
some seasons of the year. It appears to me that they increase
in numbers from April or May till August, and thereafter gradu-
ally decrease till February or March. Another point, however,
sting.— -Regarding the existence of one or two tortuous tubes with striated walls, occupy-
ing the concavity of the sheath, and which I considered as the excretory duct of the sail*
vary glands, 1 have met with it on several occasions and still believe that in the species
which I am considering the salivary duct may not empty itself into the tube of the hypo-
pharynx, but runs through its base lying free in the concavity of the sheath. This sup-
position has been strengthened in my mind by a precedent which I have just read in
Packard’s Text-Book of Entomology', p. 78 where he quotes from Meinert the following:
"‘The efferent duct of the thoracic salivary glands (ductus salivalis) perforates the
hypopharynx, more or less near the base, that the saliva may be ejected through the canal
into the wound, or that it may' be conducted along the labellac. Very rarely the salivary
duet perforating the hypopharynx , is continued in the shape of a free , very slender tube."
Medical Classics
604
requires to be borne in mind, inasmuch as it affords an explana-
tion of the recurrence, hitherto unaccounted for, of yellow-fever
epidemics without new importation, in localities previously con-
sidered as immune. I allude to the hibernation of mosquitoes,
a phenomenon which is not observed in our climate, at least in
kbnUa; fflaxUke > U, mandibles
authorities, the r^k^modeTy ^ 2 t0 the best
m cold climates, during winter^ Tasche e , SpeC ! es . Is P ro pagated
and sct about
The Mosquito 605
Among the conditions which favor the development of mos-
quitoes may be mentioned; heat, moisture, the vicinity of stag-
nant waters, low, dark localities sheltered from the wind, and the
summer-season. It is necessary, however, to bear in mind Hum-
boldt’s observation that the abundance of mosquitoes is not al-
ways in accordance with recognizable meteorological or topo-
graphical conditions.
I have already referred to the difficulty which our mosquito,
by reason of its comparatively small wings, must experience in
its upward flight after it has filled itself with blood. It will also
be hindered by the same cause, from going far from the place
where it has accomplished its last bite, and, in general, from trav-
eling any considerable distance through the air without resting.
This circumstance will not prevent, however, its being conveyed,
hidden among clothes, caught under a hat, inside of a traveling
bag, etc., to considerable distances, after a recent bite, perhaps
carrying upon its mouth-parts the inoculable germ of the
disease.
The preferences which mosquitoes show for certain races and
individuals should also be borne in mind; the African race being,
apparently, the one least tormented by them, and the greatest
sufferers being the Northern races newly arrived in the tropical
regions of America. It is probable that this may be due to the
comparative thickness of the skin, and to peculiarities in the cu-
taneous capillary circulation, since those circumstances must
influence the facility with which the female mosquito will be
able to procure itself the blood which it requires in order to accom-
plish its life-cycle.
After this long, but necessary account of the habits of our
Cuban mosquitoes, and of the Culex mosquito in particular, let
us consider by what means that insect might transmit the yellow
fever, if that disease happens to be really transmissible through
the inoculation of blood. The first and most natural idea would
be that the transmission might be effected (p. 39) through the
virulent blood which the mosquito has sucked, amounting to 5
and even to 7 or 9 cubic millimeters, and which, if the insect
happens to die before completing its digestion, would be in ex-
6q 6 Medical Classics
cellent condition to retain during a long time its infecting proper-
ties. It might also be supposed that the same blood which the
mosquito discharges, as excrement, after having bitten a yellow
fever patient, might be dissolved in the drinking water, whereby
the infection might be conveyed if the latter were susceptible of
penetrating by the mouth. But the experiments of Ffirth and
other considerations arising from my personal ideas regarding the
pathogenesis of yellow fever, forbid my taking into account either
of those modes of propagation, as I shall now explain. When the
U. S. Yellow-fever Commission took their leave, two years ago,
they presented us with a valuable collection of micro-photographs
from preparations made by our corresponding Member, Dr.
Sternberg, showing what, to me, appeared to be a most striking
feature, namely, that the red blood-globules are discharged un-
broken in the hemorrhages of yellow-fever. This fact taken in
connection with the circumstance that those hemorrhages are
often unattended with any perceptible break in the blood-vessels,
while, on the other hand, they constitute a most essential clinical
symptom of the disease, led me to infer that the principal lesion
of yellow fever should be sought for in the vascular endothelium.
The disease is transmissible, it attacks but once the same person,
and always presents in its phenomena a regular order comparable
with that observed in the eruptive fevers, all of which circum-
stances suggested to my mind the hypothesis that yellow-fever
should be considered as a sort of eruptive fever in which the seat
of the eruption is the vascular endothelium. The first period
would correspond to the initial fever, the remission to the erup-
tive period, and the third period would be that of desquamation.
If the latter phase is accomplished under favorable conditions,
the patient will only show evidence of an exaggerated transuda-
tion of some of the liquid elements of the blood through the new
endothelium; if the conditions are unfavorable, a defective endo-
thelium will have been produced, incapable of checking the fig-
ured elements of the blood: passive hemorrhages will occur and
the patient may find himself in imminent danger. Finally,
assimilating the disease to small-pox and to vaccination, it oc-
The Mosquito 607
curred to me that in order to inoculate yellow fever it would be
necessary to pick out the inoculable material from within the
blood vessels of a yellow-fever patient and to carry it likewise into
the interior of a blood vessel of the person who was to be inocu-
lated. All of which conditions the mosquito satisfies most ad-
mirably through its bite, in a manner which it would be almost
impossible for us to imitate, with the comparatively coarse
instruments which the most skillful makers could produce.
Three conditions will, therefore, be necessary in order that
yellow (p. 40) fever may be propagated: I. The existence of a
yellow fever patient into whose capillaries the mosquito is able
to drive its sting and to impregnate it with the virulent particles,
at an appropriate stage of the disease. a. That the life of the
mosquito be spared after its bite upon the patient until it has a
chance of biting the person in whom the disease is to be repro-
duced. 3. The coincidence that some of the persons whom the
same mosquito happens to bite thereafter shall be susceptible of
contracting the disease.
The first of these conditions, since Dr. Ambrosio G. del Valle
has been publishing his valuable mortuary tables, we may be sure,
has never failed to be satisfied in Havana. With regard to the
ad and 3d, it is evident that the probabilities of their being satis-
fied will depend on the abundance of mosquitoes and on the num-
ber of susceptible persons present in the locality. I firmly be-
lieve that the three above mentioned conditions have, indeed,
always coincided in years when yellow fever has made its greatest
ravages.
Such is. Gentlemen, my theory; and I consider that it has been
singularly strengthened by the numerous historical, geographical,
ethnological and meteorological coincidences which occur between
the data which I have collected regarding the mosquito and those
which are recorded about the yellow fever; while, at the same
time, we are enabled by it to account for circumstances which
have until now been considered inexplicable under the prevailing
theories. Yellow fever was unknown to the white race before the
discovery of America, and, according to Humboldt, it is a tradi-
608 Medical Classics
tional opinion in Vera Cruz that the disease has been prevailing
there ever since the first Spanish explorers landed on its shores.
There also, as we have seen, the Spaniards since their first landing
have recorded the presence of mosquitoes; and with greater
insistance than in any other place in America, in the identical
sand-mounds of San Juan de Ulloa (the present site of Veracruz).
The races which are most susceptible to Yellow fever are also
the ones who suffer most from the bites of mosquitoes. The
meteorological conditions which are most favorable to the
development of yellow fever are those which contribute to in-
crease the number of mosquitoes; in proof of which I can cite
several local epidemics regarding which competent authorities
assert that the number of mosquitoes during the prevalence of
yellow fever was much greater than on other occasions; indeed,
it is stated in one instance that the mosquitoes were of a different
kind from those which were usually observed in the locality,
having gray rings around their bodies. Regarding the topog-
raphy of the yellow fever, Humboldt points out the altitudes
beyond which mosquitoes cease to appear, and in another passage
gives the limits above the sea-level within which the yellow
fever may be propagated. Finally, in the notorious case of the
U. S. Steamship Plymouth, in which two cases of yellow fever
occurred at sea, after the vessel had been disinfected and frozen
during (p. 41) winter, four months after the last previous case
had occurred on that vessel (the preceding November), the facts
can be readily accounted for by the hibernation of mosquitoes
which had bitten the former yellow fever patients, and, which,
upon finding themselves again within tropical temperatures, re-
covered from their lethargic condition and bit two of the new
men of the crew.
. v . ’ uuuumng tne necessary author-
ization, I proceeded in the following manner.
On the 30th of last June, I took to the Quinta de Garcini a
mos,u , ,o whtch had been caught before being allowed to sting,
and there made ,t b.te and fill itself with blood from the arm of a
The Mosquito 609
patient, Camilo Anca, who was in the fifth day of a well charac-
terized attack of yellow fever of which he died two days later.
I then picked out F. B., one of twenty healthy non-immunes who
have continued until now under my observation, and made the
same mosquito bite him. Bearing in mind that the incubation
of yellow fever, in cases which allow its limits to be reckoned,
varies between one and fifteen days, I ordered the man to be
kept under observation. On the 9th of July, F. B. began to feel
out of sorts, and on the 14th he was admitted to the Military
Hospital with a mild attack of yellow fever perfectly character-
ized by the usual yellowness, and albumin in the urine which
persisted from the third till the ninth day.
On the 1 6th of July, I applied a mosquito at the same Quinta
de Garcini, to a patient, Domingo Rodriguez, in the third or
fourth day of yellow fever; on the 2.0th, I allowed the same mos-
quito to bite me and, finally, on the 22nd I made it bite A. L. C.,
another of the 20 men who are under observation. Five days
later, this man was admitted at the Hospital with fever, severe
headache, pain in the loins and injected eyes; these symptoms
lasted three days, after which the patient became convalescent
without having presented any yellowness nor albuminuria. His
case was, however, diagnosed as “abortive yellow fever” by the
physician in charge.
The 29th of July, I made a mosquito bite D. L. R. who was
going through a severe attack of yellow fever at Quinta de Gar-
cini, being then in its third day. On the 31st, I made the same
mosquito bite D. L. F., another of my 20 men under observation.
On the 5th of August, at 2 a. m., he was attacked with symptoms
of mild yellow fever; he subsequently showed some yellowness
but I do not think that he developed any albuminuria; his case
was, nevertheless, diagnosed “abortive yellow fever.”
Finally, on the 31st of July, I applied another mosquito to the
same patient, D. L. R. at Quinta Garcini, his attack having then
reached its fifth day and proving fatal on the following one. On
the 2d of August I applied this mosquito to D. G. B., another of
my twenty non-immunes. Till the (p. 42) present date (12th)
5xo Medical Classics
this last inoculation has not given any result; but, as only 12
days have elapsed, the case is still within the limits of mcuba-
I have to state that the persons mentioned above are the only
ones who were inoculated with mosquitoes, in the manner de-
scribed; and that since June iath, till now (in the course of seven
weeks), barring my first three inoculated men, no other case of
confirmed or abortive yellow fever has occurred among the twenty
non-immunes, whom I have had under observation . 2
These experiments are certainly favorable to my theory, but I
do not wish to exaggerate their value in considering them final,
although the accumulation of probabilities in my favor is now
very remarkable. I understand but too well that nothing less
1 This inoculated man D. G. B., came to my office on the 17th of August to be inspected,
stating that during the previous six days he had been suffering from headache, loss of
appetite and general malaise- On the :24th I found that he had fever (Pulse 100, Temp.
30.1), and he stated that it had been higher on the previous day and also that same morn-
ing. The fever however was never severe, and the patient did not report himself sick nor
take any medicine. The fever ceased, but the pain in the head continued a few days
longer.
Another of my 20 non-immunes was bitten on the 1 5th of August by a mosquito which,
2 days before, had bitten a patient in the Military Hospital, in the 5 th day of yellow fever.
This inoculated man does not appear to have been sick so far (September 1st). I have
not been able to see him since his inoculation, and it is only from hearsay that I have been
informed that he has felt poorly on the 24th and 25th of August; but did not report
himself sick.
2 There was a fourth case which was also diagnosed as “abortive yellow fever’* at the
Military Hospital, but regarding whose diagnosis Dr. Delgado and 1 were doubtful. He
was one of the 20 non-immunes of our group, and a different kind of inoculation was tried
upon him, the particulars of which will be considered of some interest at the present day. — *
On the 28th of June 18S1, 7 a.m., a night mosquito (C. pungens) was found inside the
mosquito-net of a fatal case of yellow-fever, in the 5th day of attack. Placed in a glass
cage, the pungens discharged some black blood upon the sides of the tube, the following
day. On the 26th of July, a couple of drops of sterilized distilled water was used to dis-
solve the dry bloody excrement and the same was soaked up with a small bit of sugar,
which looked thereafter as if it had been soaked in black coffee. A freshly caught C.
mosquito was now introduced in the phial, and went greedily for the sugar. A little
more water was now added, turning the sugar into a reddish brown syrup, from which
the same C. mosquito, in the course of h hour had taken a good feed.— On the 29th of
July, 2 p.m., L. G. P. one of my 20 non-immunes, was bitten by this C. mosquito.— On
the 3 ist of July this man was admitted to the Military Hospital with fever, flushed face,
nidSfcT 'J"-- 0 " *' ^ of A«f* ho hod
The Mosquito 611
than an absolutely incontrovertible demonstration will be re-
quired before the generality of my colleagues accept a theory so
entirely at variance with the ideas which have until now pre-
vailed about yellow-fever. In the mean time, I beg leave to
resume in the following conclusions the most essential points
which I have endeavored to demonstrate.
(p. 43) CONCLUSIONS
1. It has been proved that the C. mosquito, as a rule, bites
several times in the course of its existence, not only when its bite
has been accidentally interrupted, but even when it has been
allowed to completely satisfy its appetite; in which case two or
more days intervene between its successive bites.
2. Inasmuch as the mouth-parts of the mosquito are very well
adapted to retain particles that may be in suspension in the liq-
uids absorbed by that insect, it cannot be denied that there is a
possibility that said mosquito should retain upon the setae of its
sting some of the virulent particles contained in a diseased blood,
and may inoculate them to the persons whom it afterwards
chances to bite.
3. The direct experiments undertaken to decide whether the
mosquito is able to transmit yellow fever in the above stated
manner, have been limited to five attempted inoculations, with a
single bite, and they have given the following results: One case
of mild yellow-fever, perfectly characterized, with albuminuria
and icterus; two cases diagnosed as “abortive yellow fever” by
the physicians in charge; and two ephemeral fevers without any
definite characters. From which results it must be inferred
that the inoculation with a single bite is insufficient to produce
the severe forms of yellow fever, and that a final decision as to
the efficacy of such inoculations must be deferred until oppor-
tunity is found for experimenting under absolutely decisive con-
ditions, outside of the epidemic zone.
4. Should it be finally proven that the mosquito-inoculation
not only reproduces the yellow fever, but that it constitutes the
regular process through which the disease is propagated, the con-
ditions of existence and of development for that dipterous insect
6l2
Medical Classics
-would account for the anomalies hitherto observed in the prop-
agation of yellow fever, and while we might, on the one hand,
have the means of preventing the disease from spreading, non-
immunes might at the same time be protected through a mild
inoculation.
My only desire is that my observations be recorded, and that
the correctness of my ideas be tested through direct experiments.
I do not mean by this that I would shun the discussion of my
opinions; far from it, I shall be very glad to hear any remarks or
objections which my distinguished colleagues may be inclined
to express . 1
1 N. B. The notes do not belong to the original paper. — C. F.
Yellow Fever: Its Transmission by
Means of the Culex Mosquito
BY
CHARLES FINLAY, M.D,
Published in The American Journal of the Medical Sciences, n.s* 92: 395-409, 1886
N THE month of May, of last year, when the
yellow fever epidemic was commencing at Vera
Cruz, Dr. Carmona, of Mexico, inoculated six
prisoners with the dried residue of yellow fever
urine. In two of the six, the local symptoms
of the inoculation were immediately followed
by those of fatal yellow fever, and, a few days later, both died
on the same day (Carmona, Lemons sur V etiologie et la prophylaxie
de la Jievre jaune, p. 265). This unfortunate result agrees with
the views I have entertained since 1881, viz., that whereas the
disease is not spontaneously transmissible by infection through
the air nor by contact, it can be communicated by inoculation.
In searching for a natural agent capable of fulfilling this condi-
tion, I was led to fix upon the Culex mosquito as the most likely
one. Before submitting, however, the experimental results
which, so far, appear to confirm my theory, it will be necessary
to describe the habits and peculiarities of this insect.
Most books on natural history inform us that only the female
mosquito stings human beings and animals for the purpose of
sucking their blood, the males feeding only on sweet juices or
nutrient liquids. The fecundated females, in cold climates,
hibernate during winter, in a state of apparent death, in dark
613
6x4 Medical Classics
corners, in cellars, etc., to revive with the return of warm weather,
when they will lay eggs and propagate their species. I was un-
able, however, to ascertain from previous writers whether gnats,
in general, suck blood more than once, how long they live after
their first bite, and many other particulars essential for my
investigation. I was, therefore, obliged to undertake a syste-
matic study of the species generally found in Havana, to which
alone the following remarks must be understood to apply, leaving
future inquiries to determine (p. 396) whether the same may be
true of others that are known to exist in the interior of the island
and in foreign countries.
Two species of mosquitoes are commonly observed in Havana.
One, the Culex cubensis (La Sagra),zajJcudo, or long-legged mos-
quito, is from five to six mm. in length, of a yellowish or fawm
color, with long, thin legs, and no noticeable spots upon its body
or legs. This species is nocturnal, coming out exclusively at
night and retiring before daybreak; they are often found in the
morning, in a state of torpor, gorged with blood, inside of mos-
quito nets. I have never succeeded in getting these zancudos to
sting a second time after they had once become filled; but as they
can be kept alive, by feeding with sugar, over a period of forty
days, it is unlikely that they should not bite more than once
when in a state of freedom. The female of this species lays its
eggs pretty much in the same manner as the European gnat, de-
scribed by Reaumur, forming a boat-like aggregate of eggs, where
over one hundred are closely packed together, standing upright,
side by side, the tiny raft being left floating upon the water.
The other species is the Culex mosquito (Robineau Desvoidy),
lately described, I am told, as c< Culex fasciatus.” There are
several varieties, principally distinguishable by their dimensions
and shades of color; some being small and nearly black, while
others are stronger, almost as large as the nocturnal species, and
of a brown or steel color; the general characteristics being the
same m the two or three varieties that I have observed.
The body of the C. mosquito is dark colored, the ventral sur-
face coated with a thick skin and marked with gray or white
rings; on each side of the abdomen is a double row of white dots.
Yellow Fever
6i 5
between which stretches a transparent membrane through which
the blood can be seen when the insect is full. The most striking
feature consists in five white rings on its hind legs, corresponding
to the tarsal and metatarsal articulations. Others less apparent
are on the fore and middle legs; white spots are visible on the
sides of the thorax and front of the head, while the corselet pre-
sents a combination of white lines in the figure of a two-stringed
lyre. The wings, when closed, do not cover the end of the body.
The males are known by their bushy antennae and long palps
lying close to the proboscis, and curved outward near the point;
whereas the females have delicate antennae and short palps
drawn up close to the root of the proboscis.
The female of this species lays its eggs in a different manner
from the zancudo , not in a boat-like aggregate but singly, having
previously deposited a viscous substance through which they lie
scattered in irregular groups, either upon the liquid surface or
upon the sides of the vessel, close to the water’s edge.
The above details are easily made out with the aid of a mag-
nifying (p. 397) glass. I need not enter upon a minute descrip-
tion of the six pieces which constitute the sting of the female
mosquito (labrum, mandibles, maxillae, and tongue); suffice it
to say that, in the act of biting 1 and sucking blood it represents a
hollow lance, from 1 to mm. long, 1 /30 mm. broad at its base
and about 1/40 near its extremity. The point is shaped like
that of a writing pen, its edges being provided with ten or twelve
sharp teeth decreasing in size as they reach the finely pointed
extremity. The shaft presents transverse serrated ridges, which
must act somewhat like the teeth of a conical file; these ridges,
as well as the terminal teeth, belonging to the mandibles which
are closely applied upon the sides of the labrum.
The sting remains enclosed in a brown, hairy sheath, excepting
when it is introduced into the skin; during this operation, the
sheath, which is slit in front to within a short distance of its point,
bends backward and the sting appears like a fine wiry lance.
This generally penetrates to a depth of from i§- to 1 mm. before a
l This term is used in accordance with general custom notwithstanding its obvious
inaccuracy.
(jj 6 Medical Classics
bloodvessel is reached of sufficient calibre to allow blood to be
drawn. The insect requires from one to five or seven minutes to
complete this operation. When once it has fairly implanted its
sting, the mosquito can be easily covered with a glass tube or
phial and imprisoned. I have generally resorted to this means
in order to procure live specimens, so as to be sure of their efficacy
for my experiments.
The C. mosquito is diurnal and crepuscular, making its appear-
ance early in the morning, again between 9 and 10 a. m., and in
the afternoon until night. Stragglers may be met as late as 10
or n p.m., and in close, dark rooms they are generally felt or
heard throughout the day (in summer). The males are the first
to make their appearance, apparently attracted by the emana-
tions of human perspiration from the body or from worn clothes;
they keep flying about until the females appear, and it is only
after pairing that the new females are able to sting and draw
blood. When caught as they emerge from their pupa-case,
they often attempt to do so, but their proboscis bends, either
from want of rigidity of the sheath, or from obstruction at its
point, and the lance fails to pierce the skin. Immediately after
pairing, however, the insect is ready to sting.
I have found no difficulty in getting this species to do so as
often as it has completed the digestion of the blood previously
sucked, but not before an interval of from two to five days (ac-
cording to the season and the weather), when the insect had been
able to fill itself completely. As a proof of the remarkable re-
sistance of this insect to rough usage, and in order to exemplify
some of its habits, I copy the following record from my note-
book:
(P- 39*0 January /j, 1881. A fresh female C. mosquito was
caught in the afternoon and allowed to fill with blood off my hand,
being retained captive in a glass tube closed with a muslin cap.
15th. Filled again from my hand, biting through the muslin
cover. 0
16th. Strong and active; still distended with blood, refuses
to sting.
17th. Stings my hand readily through the muslin and fills.
Yellow Fever
617
18th. Though still retaining some blood, bites my hand readily
through the muslin. Two hours later, not having apparently
taken its usual quantity of blood at the previous bite, it stings
again and sucks during two minutes. (Probably the interposi-
tion of the muslin interferes with the act of sucking.) At this
period, knowing that only the fecundated females draw blood, I
introduced a small quantity of water into the phial, in order that
eggs might be laid. The insect immediately goes to the water,
and after discharging a whitish viscid substance upon the sides
of the tube, deposits some white eggs, close to the edge of the
water. Six of them were disposed vertically one above the other.
The rest of the day the insect was busy besmearing every part of
its body (legs, wings, and head included) with a viscid substance
collected with the hind legs from the posterior extremity of the
body. The white eggs turned black after some hours.
jgth. Continues laying eggs.
20th. More eggs; some upon the sides of the phial; stings my
hand and sucks readily. The water becomes colored red from
the excrementitious particles discharged into it.
21st. Refuses to sting; has lost its left hind leg.
22d. Still laying. One small wriggler has been hatched. Can-
not be got to sting.
23d. More eggs laid. Refuses to sting.
24th. The water is teeming with wrigglers. The insect was
now transferred to another phial with water. Stings my bare
hand very readily, taking about seven and a half minutes to fill.
23th. Refuses to sting. No new eggs.
26//;. Bites readily, but, unable to reach a bloodvessel, with-
draws its sting, and after feeling the surface of the skin, finds a
more convenient spot, where it fills completely.
27//;. Refuses to sting. In moving the phial the insect was
soaked by the water, but recovered.
281/1. Has laid over fifty eggs since yesterday evening; bites
readily, and fills from my hand.
29th. Refuses to sting. No new eggs. Most of the white
marks upon the body of the mosquito have nearly disappeared.
Jfst. Bites readily, and fills from the palm of my hand.
6j 8 Medical Classics
February 2. Bites, and fills from my thumb. Having been
transferred to another phial with fresh water, was found lying
partly submerged and motionless. On filtering off the water
the insect revived. It was then transferred, to a new dry phial
for the purpose of continuing the observations during my trip
to New York.
jd. Still retains some black blood; has lost its left foreleg.
4th. Bites, and fills from my hand. Taken on board of the
steamer starting for New York.
5th. Refuses to sting.
6 th. Bites, and fills readily.
(p. 399) 7//;, 8 th, 9th, 10th. Alive, but refuses to sting. The
weather was quite cold, the last three days passed off Sandy
Hook.
12th. The phial, packed in a valise, was sent by express to
Orange, N. J.; the insect arrived nearly dead.
13th. Dead, after thirty-one days captivity, having bitten
twelve times, and laid probably over two hundred eggs.
From inquiries made on the steamer, I ascertained that mos-
quitoes are rarely felt on board during the three or four days
that the vessel is detained in the port of Havana, where she lies
at a distance from the wharves. In New York, where the ship
goes to the wharf, they are apt to be more troublesome, but gen-
erally disappear soon after the vessel has left the port.
Mosquitoes are observed in Havana all the year through, but
much more so from May to October. In winter they are rare
when the temperature falls below 70° F. Last year (1885) has
been an exception to the general rule. Mosquitoes, especially
the diurnal species, were difficult to procure throughout the sum-
mer; but became more numerous in the latter part of September,
October, and November. A remarkable scarcity of yellow fever
cases was likewise observed in the summer months, and I called
attention to this coincidence at one of the sessions of our Acad-
emy In October and November more cases of the disease were
signalled, both m hospital and private practice, than in the pre-
' 10us mon ths °f the year, although the summer heat had been
Yellow Fever
619
more intense than usual, and had abated toward the end of
September, in October and November the weather being quite
mild.
Although great differences are observed in the duration of the
successive phases of development of the C. mosquito, the follow-
ing data may be taken as a fair average: Every mosquito that
stings may be considered as a fecundated female, and will prob-
ably lay eggs within a few days after its bite, provided it can
find water upon which to lay them. In water-jugs standing in
bedrooms, the insect is often found depositing its eggs either on
the sides of the jug or upon the water. The eggs are commonly
hatched, producing minute wrigglers, between the second and
fourth day, in summer; some are delayed much longer, and those
that are deposited outside the water may remain a long time in
the dry state without losing their vitality. The wrigglers grow
more or less rapidly according to the nutritive material contained
in the water, the temperature, etc., but they probably pass into
the pupa stage within twelve or fo'ur'teen days. This stage is
always short, not lasting more than two or three days, the fully
developed mosquito emerging from its aquatic case a fortnight or
three weeks after the egg was laid.
From the above data it will be understood how a single infected
mosquito, which happens to be conveyed to a healthy locality,
when the temperature and altitude are appropriate, might, if
my theory be true, (p. 400) inoculate the disease to any liable
subject whom it should there sting; and, according to the usual
rate of incubation, at the end of a fortnight or three weeks, the
consequent attack of yellow fever would be at its height. In the
meantime the imported insect would have produced a whole
brood of its own species, probably in the vicinity of the place
where the patient is lying; thus providing the necessary condi-
tions for the subsequent propagation of the disease.
It remains, therefore, to be determined whether the limits of
temperature and of altitude within which the C. mosquito is able
to exert its functions, agree with those which are known to limit
the propagation of yellow fever. The following simple experi-
ments appear conclusive on these points:
620
Medical Classics
i. Let a female C. mosquito, of medium size, be placed in a
test-tube with a thermometer passing through the cotton-p ug,
and the tube dipped in water, the temperature of which is
gradually lowered by the addition of ice and salt. The following
effects will be observed:
Between 66° and 6o° F., the insect is benumbed, scarcely
moving, sometimes falling to one side in a state of apparent death.
Between 6o° and 3a 0 F., apparent death more pronounced.
If the water be allowed to return to its former temperature:
Between 6o° and 65° F., the insect shows signs of life.
Between 65° and 68° F., it is able to walk and fly.
Above 77° F., it recovers its former agility, but is at first un-
able to bite; indeed, if the cooling has reached 3a 0 F., or below,
the insect generally dies within a short time.
The larger varieties seem, however, to bear low temperatures
better than the small, and a difference is observed according as
the change is effected more or less rapidly.
2 . In order to test the limits of heat, let a test-tube, similarly
disposed, with a thermometer and live mosquito, be suspended
inside of a large empty flask, standing in a basin of hot water.
The following effects will be noted:
Between 95 0 and ioo° F., the insect appears uncomfortable.
Between ioa° and 105° F., remains motionless in apparent
death, but is apt to recover and to sting again when restored to a
normal temperature.
From 105 to 1 io° F., apparent or actual death; the insect, if it
does revive, not being able to sting again, and generally dying
within a few hours.
3 - As regards barometric pressures, the experiment would best
be tried m such localities as Vera Cruz, Orizava, and Mexico,
or in Rio Janeiro and the heights near it, but, failing that resource,
1 have contrived the following plan:
A female C , r f osc l uko 5s P ]aced ^ an empty bottle connected
height" aner ° ld bar ° meter > and a suction fla sk raised to a proper
At rarefied pressures corresponding to aooo or 3000 feet, the
Yellow Fever 621
insect becomes at first unable to fly, but if withdrawn will bite
and draw blood after a while.
At rarefied pressures corresponding to 4000 or 6000 feet, the
the general effects are more marked, but the insect does not die,
and seems even to (p. 401) get accustomed to the new state of
things; but when withdrawn continues weak, and unable to
sting for several hours.
We are thereby led to infer that the C. mosquito, when sud-
denly transferred to heights above 3000 or 4000 feet, must find
it difficult to exert its functions, and that it would never, of its
own accord, seek elevations which render its flight difficult. This
conclusion agrees, moreover, with the remarks of Baron von
Humboldt, who carefully observed the mosquitoes of Central
America.
From the above experiments it is inferred that the limits of
functional activity for the C. mosquito are: as regards tempera-
ture, between 60° and ioo° F., the insect reviving, however, after
having been chilled to near 32 0 F., or warmed to 105° F.; as re-
gards altitude, from the level of the sea to 3000 or 4000 feet.
Now the limits which most observers assign to the propagation
of yellow fever are temperatures ranging from 6o° F. to 90° F.
(“Barton’s Reports,” 1852, pp. xiii. and 283); a general tempera-
ture of 32 0 F. having, however, proved ineffectual to prevent the
recurrence of the disease (in the case of the “Plymouth”), when a
tropical temperature was produced. As regards altitudes, the
highest limit at which it has been observed seems to be 4000 feet
above the level of the sea.
Before dismissing the subject under consideration, I must add
that the mosquito finds within the precincts of a dwelling all the
requirements for its development, growth, and reproduction;
dark corners to hide in, stagnant water in which to lay its eggs
and to develop its larvae, and substances for the female insect to
feed on, being the principal conditions. A forgotten tub, or
pool of stagnant water in a back yard or garden, is often chosen by
the insects as a place of rendezvous where they congregate and lay
5 22 Medical Classics
their eggs; the larvae, in the meantime, going through their
successive stages of development. The mother insect when about
to die, has been observed to resort to the water where its larvae
are growing, its cadaver remaining floating upon the liquid sur-
face. The nocturnal species will naturally lead a more stationary
existence than the diurnal; for the latter, in trying to sting during
the busy hours of the day, will often have, to follow its intended
victim from house to house, returning again and again after being
driven off, until it succeeds in planting its sting and filling with
blood. Wherever the bite happens to have been successful,
there the mosquito will, in all likelihood, take up its quarters;
it will develop a new brood and continue to sting all that come
in its way, unless again led off by a chance peregrination.
Before relating the following six cases of experimental yellow
fever, it will be proper to explain the general principles by which
I was guided, and the process which I have followed in my inocu-
lations.
The general disposition of the C. mosquito’s sting has already
been described, but for our present purpose it may be regarded as
a slender (p. 402) hollow needle from ^ to ^ mm. broad and
2 mm. long, with its sides roughened by a series of trans-
verse ridges and its point armed with teeth. This needle pene-
trates through the skin until it reaches one of the capillaries of
the corium, generally to the depth of 1 to 2 mm., remains in
position during a space of from one to five minutes, and, after
being rvithdrawn, will continue protected by its sheath against
external agents until the insect’s next bite. I have been able to
prove that the sting often retains spores of microscopical fungi,
which may be made to develop by keeping the proboscis in a
sterilized cell, and I once found upon the side of the sting a
finely developed bunch of spores like those observed in yellow
fever blood cultures by Dr. Sternberg {Bacteria, 2d edition, p.
426), and classified as “Penicillium;” whence it is to be inferred
that it may likewise retain upon its outer surface or inside of its
sheath, such minute disease-germs as are generally believed to
mn!n S10 f ° Zym0tic leases. If SO, the sting of the
mosquito having been impregnated with the animal juices during
Yellow Fever
623
the operation of stinging, may constitute an appropriate soil for
the preservation or even for the culture of those germs; might it
not, indeed, be the “intermediate host” necessary for some phase
of their development? 1
For the purpose of carrying into effect this novel inoculation,
my plan has been to catch a female mosquito while in the act of
stinging and before it has filled, by inverting an empty phial or
test-tube over it and closing the mouth of the phial with a plug of
cotton-wool. The insect is thus in readiness to renew its bite as
soon as it has become accustomed to its place of confinement.
Indeed, it will die of inanition if not allowed to do so in the course
of a few hours (four to twelve in summer). The captive is then
taken to a confirmed case of yellow fever, and the tube being
inverted and the cotton plug carefully removed over the bare
surface of the patient’s arm or hand, the insect is allowed to fill
at leisure with the tainted blood, and the plug reinserted. After
this blood has been digested, generally between the second and
fourth day, the mosquito is applied in the same manner to the
arm of a subject liable to the disease, and then allowed again to
fill itself completely. This is the inoculation; and when success-
ful, at the end of from five to twenty-two days incubation, the
first symptoms of mild yellow fever will manifest themselves in
the inoculated subject.
The process, as above described, is simple enough, but it must
be observed that in order to obtain available results several con-
ditions are necessary. A case of yellow fever must be at hand at
the period most favorable for the transplantation of the virus,
which, according to my (p. 403) experiments, seems to be from
the third to the sixth day. A liable subject must be found willing
to submit to the process, supposed to be free from previous infec-
tion, and likewise willing to keep clear from infected places during
the incubation, yet within easy reach of observation.
The nocturnal species of mosquito can easily be procured, but,
1 In resolving to experiment upon human subjects, I relied upon the inference that the
quantity of virus carried by a single sting must be a minimum dose, capable of producing
only the mildest forms of the disease ever observed in nature, and that a number of such
bites would be necessary to occasion a dangerous attack.
624
Medical Classics
as before stated, I have never succeeded in making that particular
kind sting more than once; whereas, the diurnal, which is the
only one that I have experimented with, does not generally come
in swarms, but singly, or in small numbers, making butlittlenoise,
and its bite is usually unfelt, at least by the acclimated.
These requisites, so difficult to be obtained by one whose leisure
hours, in the midst of an active professional life, are necessarily
limited, will account for the small number of my experiments,
some twenty-four individuals only having been inoculated by me
since June, 1881. Of this number only one has died of yellow
fever; he had been inoculated in November, 1883, without any
visible result, and was attacked, after severe exposure; in June,
1884, with a malignant form of yellow fever (it is the second case
of the series referred to elsewhere as instances of contagion).
Of the remaining twenty-three, two left the country, or were lost
sight of the first summer after inoculation, the rest having re-
mained under observation during periods ranging between one
and four full summers in the city of Havana. Six of these inocu-
lations -were follow 1 ed within the ordinary limits of yellow fever
incubation (five to twenty-two days), by an attack of fever, the
exact counterpart of mild attacks of yellow fever, of which I
have kept careful notes, and which v r ere proved by subsequent
observation to have conferred immunity. Eleven inoculations,
though not followed by any morbid manifestation, at the end of
several months a mild attack of yellow fever (without albumin-
uria) was observed.
# These figures are not considered, from a statistical point of
view, to afford any definite clue either in favor of or against the
prophylactic value of my inoculations when not followed by a
mild attack of the disease, and it is rather upon the circumstances
attending my six successful inoculations that I rely in order to
prove the aptitude of the C. mosquito for transmitting yellow
ever. this be once admitted, it must follow that the disease
is actually so transmitted, since it must constantly happen, in a
place like Havana, that unacclimated subjects (p. 404) are stung
by mosquitoes which have previously bitten yellow fever pa-
Yellow Fever
625
My first inoculations by means of mosquitoes were performed
under the following circumstances: A group of twenty unaccli-
mated soldiers, who were quartered on the heights of the Cabanas,
on the other side of the bay, were picked out for my observations,
and were only allowed to cross the bay in batches of four or five
on the days they were sent to my office, where I tried their blood
for hematimetric purposes. Five of the group were inoculated
by me at different dates between the 29th of June and the end of
August, 1881. The first three were followed, at the end of five
or fourteen days’ incubation, by an attack of fever of several
days’ duration, diagnosticated by the attending physicians at the
military hospital as “regular yellow fever” in the first case, and
“abortive yellow fever” in the two others. The fourth inocu-
lated soldier suffered only from continued headache, and, on the
fifteenth day after the inoculation, came to my office with slight
fever (temperature 100.7° F., pulse 100), but was not laid up.
The fifth did not return to my office. I was informed that he
had felt poorly a few days after the inoculation, but was not laid
up. I have been able to trace the history of these five cases until
the beginning of last year. None of them had been reported, up
to that date, as subsequently attacked with yellow fever. Of the
remaining fifteen soldiers of the group, upon whom the inocula-
tion was not performed, none were attacked with yellow fever dur-
ing the period of my observation, June 28 to September, 1881.
Case I — On the 30th of June, 1881, one of the soldiers of the
above group (F. B.), twenty- two years of age, three months in
Havana, having had previously some attacks of intermittent
fever, was inoculated by means of a mosquito which had bitten,
two days before (June 28th), a patient in the fourth day of yellow
fever and who died thirty-six hours later.
July 14. The inoculated soldier was taken sick and went to
the Military Hospital, where I was only able to see him on the
1 6th (third day of his illness). I found him with slight fever,
slight yellowish tinge of conjunctivae, pains of invasion almost
disappeared; the urine gave distinct evidence of albumen with
heat and with nitric acid, not having presented any in the morn-
5 2 6 Medical Classics
ing. The clinical report of the attending physician, together
with my own observation, gave the following result.
jst day, July 14. Invasion preceded by a few days of discom-
fort.
2d day. Morning: Temp. 101.8 0 F.; pulse 92; resp. 28; face and
eyes injected; intense headache; slight epigastralgia; pains in the
spine; tongue coated; no vomiting or other remarkable symptoms.
Treatment: Ipecacuanha four grammes in four doses; cream of
tartar lemonade; absolute diet. Evening: Temp. 100.4° F.;
pulse 88; resp. 26; headache less intense. Night: Intense thirst;
urine scanty.
jd day. Morning: Temp. 99.6° F.; pulse 72; resp. 34, skin
pale; slight yellowness of conjunctivae; congested gums; epi-
gastralgia; no nausea; no albumen in the urine. Evening:
Albumen detected in the urine. Night: Same condition; in-
somnia. Treatment: One gramme of sulphate (p. 405) of qui-
nine in ten doses; cream of tartar lemonade; mustard plasters to
the extremities.
4ih day. Morning: Temp. 98.9° F.; pulse 72; resp. 34; no
headache; some appetite; gums give a little blood on compres-
sion; urine treated by heat and nitric acid, gives a more abundant
precipitate of albumen. Evening: Normal temperature and
pulse.
jth day. Temp. 98.9° F.; pulse 78; respiration normal; slight
jaundice; urine contains albumen.
6th day. Convalescent; urine not examined; broth allowed.
yth day. Continues well.
12th day. Cured.
The distinct evidence of albumen in the urine, notwithstanding
the mildness of the fever and general symptoms, leaves no doubt
regarding the diagnosis, which was unhesitatingly reported as
regular yellow fever.”
Case II.— Another soldier of the group (A. L. C.), seventeen
years of age, three months in Havana, was stung on the nd of
July, 1881 by a mosquito which had bitten, on the 16th, a bad
case of yellow fever (in fifth day of his illness), and on the loth
nad been made to sting my own hand.
y ) 27. Fn e days after the inoculation, this soldier entered
Yellow Fever
627
the Military Hospital with an attack of fever, which was quali-
fied as “abortive yellow fever.” When seen by me on the 31st
(fifth day of his illness), there was .scarcely any fever, and the
urine contained no albumen. I was unable to procure the clini-
cal notes of this case.
This observation would tend to prove that an infected mosquito
does not always lose its virulence by an intermediate bite. This
is not always the case, however, for on a subsequent occasion,
having inoculated with a mosquito which had bitten two yellow
fever patients, a person who seems thereby to have acquired sub-
sequent immunity, the same insect was afterward made to sting a
second non-acclimated person, who had a severe attack of yellow
fever six months later, from which he fortunately recovered.
This case has not been included among my regular inoculations,
being considered a distinct experiment.
Case III. — A third soldier (D. L. F.), twenty years of age, and
six months in Havana, was inoculated on the 31st of July, 1881,
with a mosquito which had bitten, two days before, a fatal case
of yellow fever in third day of the disease. On the 5th of August
(five days after the inoculation) the soldier came to my office,
presenting temp. 39.6°, and pulse no. He was at, once sent to
the Military Hospital, where the following clinical record was
taken:
1st day , August 5. Evening: Temp. 103.2° F.; pulse 112; in-
tense headache; slight epigastralgia; flushed countenance; in-
tense thirst. Treatment: Valerianate of quinine two grammes
in twenty pills; mustard plasters to the extremities; cold applica-
tions to the forehead.
2d day. Morning: Temp. 100.7° F.; pulse 72; resp. 28; the
pains have lessened; some nausea; subicteric tint; urine pretty
abundant, contains no albumen. Evening: Temp. 101.8° F.;
pulse 88. Night: Temp. 100.7° F.; pulse 82; insomnia.
(p. 406) 3d day. Morning: Temp. 99.6° F.; pulse 76; per-
spiration; no pains. Evening: Temp. ioo° F.; pulse 80; restless-
ness.
4th day. Apyrexia.
628 Medical Classics
The diagnosis, as stated in the clinical report, was abortive
yellow fever.”
The following year (188a) my attention was principally devoted
to the observation of mild forms of yellow fever, in order to collect
reliable data available for the appreciation of my experimental
cases. In 1883, however, I resumed my experiments, obtaining
three successful inoculations, one of which (Case V.) is particu-
larly worthy of notice.
Case IV. — A Spaniard (J. B.), employed as a servingman to
my friend Dr. Delgado, twenty-five years of age, nine months
in Havana, having never been ill since his arrival, was inoculated
on the 22d of June, 1883, by two mosquitoes, which had both
bitten, two days before, a fatal case of yellow fever in the sixth
day of his illness.
July gth (seventeen days after the double inoculation), J. B.
was taken ill with symptoms of yellow fever. The following
morning an emetic was administered, followed by a dose of castor
oil; no other medicine being given in the course of the illness, and
absolute diet maintained until the sixth day, only water being
allowed.
2d day. Morning: Temp. 101.3 0 F.; pulse 80; face flushed;
pains in the loins. Evening: Temp. 101.8 0 F.
3d day. Morning: Temp. 100.4° F.; pulse 70; no albumen . in
the urine. Evening: Temp. 101.8 0 F.; face less flushed; straw
color of the conjunctiva; intense thirst; anorexia.
4th day. Morning: Temp. 99.5 0 F.; pulse 68; no albumen.
Evening: Temp. 101.3 0 pulse 70.
5th day. Morning: Temp. 100.4° F.; pulse 68; no albumen;
conjunctivae yellowish; gums do not bleed on pressure.
6th day. Morning: Temp. 101.4 0 F.; pulse 72. Midday:
Temp. 103. 1 F.; pulse 72. Evening: Temp. 103.2 0 F.; pulse 70.
7 th day. Morning: Temp. 98° R; pulse 54; yellowish tinge
on the forehead; no pains; has perspired freely in the night; milk
rapiTconralicence 76 ” 1 ’' 98 ' 6 ” ^ ^ 525 appctite retuming;
Yellow Fever
629
The general type of the fever, with remission on the fourth
day, and defervescence on the seventh, bears a strong resem-
blance to some forms of natural yellow fever that I have observed.
The patient has since remained protected.
The following case is remarkable from the circumstance that
most of the conditions were fulfilled that can well be secured in
the vicinity of Havana, in order to avoid the chances of independ-
ent infection from other sources besides the inoculation. The
place selected for the experiment was the same country residence
or “Quinta” rented by the Jesuit Fathers since 1872, near the
“Quemados de Marianao,” to which Dr. Stanford E. Chaille has
alluded in his remarkable report as President of the Yellow Fever
Commission which visited Havana in 1879 ( Annual Report of the
National Board of Health, Washington, 1880, p. 276 (p. 407)).
In the course of eleven years (1872-1883), the only case of yellow
fever developed among the many liable subjects who had spent
their summer vacations at this place, during their stay, occurred
in 1880 in a young priest who had been going backward and for-
ward to Havana during the previous fortnight, and who was at-
tacked with the disease during his last visit to the city, where he
remained and died. It is more than likely that he had contracted
the infection in town, and not at the Quinta.
Toward the end of June, 1883, several young priests and a
servant, all unacclimated and having arrived from Spain the
previous autumn, happened to be staying at this country-place,
and I availed myself of their willingness to submit to my inocula-
tion experiments.
Case V. — P. U., one of the unacclimated priests, a young man
of spare habit, having gone to the “Quinta” toward the end of
June, -1 883, did not again visit the city nor the neighboring town
of Marianao until the following September. On the 15th of
July a first unsuccessful attempt was made with a mosquito con-
taminated from a case in the seventh day of yellow fever; a full
month was then allowed to elapse before a second attempt on the
same person.
630 Medical Classics
August 18, 1883, P. U. was inoculated with a mosquito which
had bitten on the 13th and 16th two separate cases of yellow
fever, each in the sixth day of their illness.
On the 26th of August, eight days after inoculation, P. U. was
taken ill about 8 A.M. with headache, pains in the loins, and
fever (temp. 100.7° F.). I saw him at 4 P. M^ and from that time
followed the case, keeping accurate notes of the symptoms.
1st day. 4 P. M., felt very poorly, complained of headache and
pains in the loins and calves; face flushed and covered with per-
spiration; eyes injected; was sent to bed, and after a while pre-
sented: Temp. 102.2 0 F.; pulse 100, dicrotic. Treatment:
Castor oil with lime juice. Night: Temp. 102.3° F.; pulse 104;
vomited five or six times through the night and had several pas-
sages; thirst; eyes injected.
2d day. Morning: Temp. 101.3° F.; pulse 88; resp. 20; eyes
injected, without yellow tinge; urine natural in appearance.
Evening: Temp. 101.4° F.; pulse 90; resp. 30; somewhat drowsy;
urine less copious than usual, acid reaction, not affected by boil-
ing. Treatment: Hyposulphite of soda; boiled orangeade for
common drink.
yd day. Morning: Temp. 101.8° F.; pulse 80; resp. 27; urine
contains no albumen; restless night, insomnia; tongue white;
thirst; face less flushed. Evening: Temp. 101.8° F.; pulse 84;
resp. 26; subicteric tinge of conjunctivae. Same treatment.
jlh day. Morning: Temp. 100.4° F.; pulse 60; resp. 27; sub-
icteric tinge more marked; the pains have ceased; urine scanty,
contains biliverdine, but no albumen; the gums bleed on pressure.
Treatment: Chlorate of potash. Evening: Temp. 101.4° F.;
pulse 80; restlessness; urine scanty, no albumen; thirst; anorexia.
5th day. Morning: Temp. 101.1° F.; pulse 76; resp. 29.
Evening: Temp. 101.8° F.; pulse 83. Night: During a thunder-
storm became very nervous; ten hours without passing urine;
urine presents traces of albumen. Treatment: Morphia syrup.
(p. 408 ) 6th day. Morning: Temp. 101.8° F.; pulse 72; urine
not altered by ebullition; quiet night; expectorated some bloody
sputa Broth allowed. Evening: Temp. 100.7° F.; pulse 75.
7 ay. i orning: Temp. 99.6° F.; pulse 62; resp. 20; subic-
Y ellow F ever 631
teric tint of conjunctivae; some bloody sputa; gums bleed on
pressure; urine scanty, no albumen. Evening: Temp. 98. 9 0 F.;
pulse 57.
8th day. Morning: Temp. 98.7° F.; pulse 58; subicteric tint
of conjunctivae.
It is worthy of notice that this patient in his normal condition
presented a polyuria insipida , amounting to over two litres per
day; the secretion becoming immediately reduced from the in-
vasion of the attack.
The patient spent two summers in the city after this attack,
visiting cases of yellow fever, and having witnessed two severe
ones in the town-college where he resided, without experiencing
any inconvenience.
Case VI. — The unacclimated servant before mentioned, who
was staying at the Jesuits’ “Quinta” with the preceding case,
and upon whom a first unsuccessful attempt had also been made
on the 16th of July, was again inoculated on the same day as
P. U.
August 18. This servant (J. S.) was stung by a mosquito which
had bitten, three days before, one of the patients of yellow fever
from whom the previous case was produced. J. S. remained at
the “Quinta” until September 3d, at which date he had to return
to the college in town. He was taken ill on the 9th and went into
a private hospital, where I was able, with Dr. Delgado’s assist-
ance, to follow up the case.
1st day. Twenty-two days after the inoculation, taken ill
in the evening, with fever, headache, and pains in the loins.
2d day. Midday: Temp. 103. i° F.; pulse 94; copious per-
spiration; headache; pains in the loins; eyes injected; tongue
coated. Evening: Temp. 103. 2° F.; pulse 96; resp. 24; urine
acid, not precipitated by boiling.
yd day. Afternoon: Temp. 100.4° F.; pulse 84; resp. 20;
urine acid, gives a distinct precipitate on being heated to the
boiling point; tongue coated; face less flushed; thirst; anorexia.
4th day. Afternoon: Temp. 99.8° F.; pulse 66; resp. 22; urine
632 Medical Classics
not precipitated by heat nor by NO,; subicteric tint of conjunc-
tivae; thirst; anorexia.
5th day . Midday: Temp. 9 9.3° F.; pulse 64; resp. 22; urine
turbid, no albumen; appetite returning.
6 th day. Afternoon: Temp. 99.8° F.; pulse 64; resp. 22; broth
allowed.
ph day. Temp. 99.3° F.; pulse 56; resp. 22; some appetite;
conjunctivae subicteric.
The fact that this person had returned to Havana six days
before the attack, together with the long incubation of twenty-
two days, leaves a doubt regarding the part that the inoculation
may have had in the causation of the disease; but, on the other
hand, the small number of yellow fever cases reported at that time
in Havana, and the circumstance that newcomers are not often
attacked so early as six days after (p. 409) their arrival in the
city, have induced me to include this among my successful in-
oculations.
From the evidence adduced in the preceding pages, I conclude
that while yellow fever is incapable of propagation by its own
unaided efforts, it may be artificially communicated by in-
oculation, and only becomes epidemic when such inoculations
can be verified by some external natural agent, such as the mos-
quito.
The history and etiology of yellow fever exclude from our con-
sideration, as possible agents of transmission, other blood-sucking
insects, such as fleas, etc., the habits and geographical distribu-
tion of which in no wise agree with the course of that disease:
whereas, a careful study of the habits and natural history of the
mosquito shows a remarkable agreement with the circumstances
that favor or impede the transmission of yellow fever. So far as
my information goes, this disease appears incapable of propaga-
tion wherever tropical mosquitoes do not or are not likely to
exist, ceasing to be epidemic at the same limits of temperature
an a titude which are incompatible with the functional activity
of those insects; while, on the other hand, it spreads readily
wherever they abound. From these considerations, taken in
Yellow Fever
633
connection with my successful attempts in producing experimen-
tal yellow fever by means of the mosquito’s sting, it is to be in-
ferred that these insects are the habitual agents of its trans-
mission. It cannot be denied, however, that other such agents
may and probably do occasionally occur, but not being endowed
with the same facilities for rapid and extensive operation, their
influence becomes insignificant as compared with the action of
the Cuban culex.
Inoculations for Yellow Fever by
Means of Contaminated
Mosquitoes
BY
CHARLES FINLAY, M.D.
Published in The American Journal of the Medical Sciences, n.s. 102: 264-26S, 1891
T THE time when my former article was writ-
ten 1 I observed that the figures there given were
not considered by me, “from a statistical point
(p. 265) of view, to afford any definite clue
either in favor or against the prophylactic
value of my inoculations.” In fact neither the
number of my experiments nor the length of time during which
the parties inoculated had been under observation could at that
time justify any scientific deductions. Now, however, the case
is different; I have on record a series of sixty-seven persons, in-
cluding all those whom, in collaboration with Dr. Delgado, I
have inoculated since 1881, by means of contaminated mosqui-
toes, in the manner explained in my previous article. All were
Europeans, with few exceptions natives of Spain, young adults
recently arrived in Cuba and presenting the usual conditions
which imply liability to contract yellow' fever. Among the
sixty-seven a considerable number, fifty-two, are considered as
acclimated, either from the fact that they have resided in the
infected quarters of the city of Havana (the old town) during
1 “Yellow Fever: Its Transmission by Means of the Culex Mosquito.” American
Journal of the Medical Sciences, October, 1886, p. 395.
634
Inoculations for Yellow Fever 635
periods varying between three and seven years, or in considera-
tion of their having experienced fevers which are attributed to the
yellow fever infection, though of a mild type in the vast majority
of the cases. Two parallel groups, one of thirty-three inoculated
persons and the other of thirty-two not inoculated , both offering
to all intents and purposes such similarity (as to susceptibility
and exposure) as can seldom be obtained, afford a reliable founda-
tion for a fair and unbiassed comparison. I consider, therefore,
that the time is now come when some practical inferences may
be drawn, and, as far as they go, I am happy to say that they
agree with my former expectations.
The statistical method of demonstration is, at best, a tedious
and a slow process, but it can boast of great triumphs, such as
are recorded in the instances of Jenner and Pasteur, who have had
to rely exclusively on its results in order to bring over to their
views the balance of scientific opinion and public favor. They
represent, moreover, two distinct applications of that method.
Jenner vaccinated indiscriminately a vast number of subjects in
order to verify subsequently the immunity enjoyed by the major-
ity when exposed to the variolous infection. Pasteur, on the
other hand, adopted the system of carefully registering every
person inoculated by his method after being bitten by a rabid
animal, the average proportion of hydrophobic cases developed
in the non-inoculated after similar bites. I have chosen Pas-
teur’s plan, believing it to be the more reliable and more appli-
cable to our case. It cannot be denied, however, that, limited as
we have been in our field of experiment, our numbers cannot com-
pare with those of the glorious French investigator, nor that we
labor under a disadvantage in having to deal with a disease which
so far has not been proved to occur, under ordinary circumstances,
in lower animals. Thus obliged to confine our investigations to
the human species, it could hardly be expected of us that we
should carry our scientific zeal to the point of seeking, through a
bolder application of our inoculations, to determine a violent
attack of the disease — thereby carrying conviction, no doubt, to
the sceptical mind, but at the risk of having betrayed the con-
fidence placed in us.
6g6 Medical Classics
A somewhat specious objection was recently raised against
our mosquito-inoculations, on the plea that the proboscis of the
insect not being susceptible of sterilization many accidental
germs might be inoculated together with or instead of yellow
fever, supposing the latter to exist in the proboscis of the con-
taminated mosquito. To this hypothetical imputation I can
oppose many facts. In none of our numerous inoculations has
such an occurrence been observed, nor has it ever been proved
that the acclimated inhabitants who are constantly being stung
by those insects acquire thereby any specific infection. I have
on several occasions introduced into sterilized tubes provided
with agar jelly mosquitoes that had stung acclimated persons.
In most of these experiments, after several days’ confinement, the
insect died for want of food, and yet not a single colony appeared
upon the jelly; when any growth was developed it mostly con-
sisted of fungi, the spores of which had probably been introduced
accidentally while transferring the insect from one tube into an-
other. From this curious result I infer that the insect has some
means of rendering its outer surface aseptic, and probably does
so through a very peculiar operation w r hich I have often seen it
perform. This consists in collecting with its hind or middle
legs a secretion expelled from the posterior part of its body, and
besmearing very persistently with it every part of its body — legs,
wings, head, and proboscis. I also believe that we are justified
in admitting that the liquid which the insect employs to lubricate
its complicated sting, and which being poured into the wound
occasions the painful sensation felt by its victim, must vary in its
chemical composition in different species of gnats, thereby ac-
counting for the difference in the sensations occasioned by their
sting. It is quite possible, therefore, that the presence of that
lquid may constitute in the sting of the culex mosquito an ap-
propriate soil for the development of the yellow fever germ,
whereas the same germ would remain sterile in the sting of other
species of culex.
Another objection of a clinical character was made to our con-
sidering as cases of mild yellow fever the attacks of non-albumin-
unc fever observed in our inoculated subjects, either within the
Inoculations for Yellow Fever 637
plausible limits of incubation or later on, with the result of render-
ing them immune against subsequent attacks of albuminuric
yellow fever. To this objection an answer is given by the pres-
ent statistics themselves, inasmuch as among fifty-six inoculated
and non-inoculated subjects mentioned therein and who have
resided during periods varying between three and seven consecu-
tive years in the city of Havana, one-half have acquired their
immunity exclusively through non-albuminuric attacks suffered
during the first three years after their arrival here. If the ob-
jection turned out to be well grounded, it would only prove that
what we had considered as a partial immunity had been a com-
plete one in ninety per cent, of our inoculated subjects.
I have distributed our sixty-seven inoculated subjects into
six groups:
Group I. Fifteen — whose observation is yet incomplete, not
having resided three years in Havana, nor experienced any form
of yellow fever.
Group II. Twelve — who experienced, within a period of
days 'varying between three and twenty-five, after the inocula-
tion, an attack of fever with or without albuminuria.
Group III. Twelve — who did not experience any pathogenic
effects within the twenty-five days following the inoculation,
nor any other febrile attack subsequently, that could be referred
to the yellow fever infection.
Group IV. Twenty-four — who did not experience pathogenic
effects within the twenty-five days, but subsequently had fevers
of a mild type, either non-albuminuric or with slight or transient
albuminuria.
Group V. Three — who experienced no pathogenic effects
after the inoculation, but were subsequently attacked with
regular albuminuric yellow fever (severe in two cases), but re-
covered.
Group VI. One — who not having experienced pathogenic
effects after the inoculation, was attacked some months later,
and after exposure to an infection of unusual intensity, with
fatal yellow fever.
After excluding the fifteen incomplete observations of Group I.,
638 Medical Classics
fifty-two cases remain to be considered which may be conven-
iently arranged under three heads:
Casa Per cent
Mild acclimation (Groups II., III., IV.) 4® 92.2
Acclimation with regular yellow fever — cured 3 5-9
Fatal yellow fever 1 l -9
52
The next point -was to obtain reliable data for comparison. I
was fortunate in receiving from two religious communities placed
under my medical charge the authorization to practise my in-
oculations on such members as would be willing to submit to
them. These communities are those of the Jesuit and Carmelite
Fathers, established in the city of Havana. Their members are
partially renewed almost every year by the arrival of new-comers
from Spain to substitute others who have resided several years
here. Since 1883, every year except 1885 I have inoculated some
of the new-comers, while others did not go through that ordeal.
During the period 1883-1890 the Jesuit Fathers have had thirty-
six inoculated and seven not, and the Carmelites had thirteen
inoculated and twenty-five not inoculated. Of the inoculated
none have died of yellow fever, whereas five of the non-inoculated
have died of it (one Jesuit and four Carmelites). After deducting
from the inoculated thirteen cases still under observation, we
have thirty-three inoculated and thirty-three not inoculated
members of the same communities, having arrived in the same
years as the former, leading the same life and exposed to the same
chances of infection.
Inoculated
Mild acclimation (Groups II., III., IV.)
Acclimation with regular yellow fever— cured g
Died of yellow fever— none of the inoculated, but of the
non-inoculated
JlTo* inoculated
Per cent
21-65!
6—15
5-JSl
33 3 2
.Tj 16 ^ onc ^ uslons which the above statistical results, together
wit t e comparative observations, appear to justify are as
Inoculations for Yellow Fever 639
1. The inoculations with one or two recently contaminated
mosquitoes, in the manner practised by ourselves, is free from
danger, inasmuch as the numerous trials which have been made
have produced at most (in about 18 per cent, of our cases) a
mild attack followed by immunity.
2. We must attribute to the influence of the inoculations with
contaminated mosquitoes: I. The mild acclimation observed
in 94 per cent, of our cases, whereas the same desirable result has
only occurred, caeteris paribus , in 65! per cent, of the non-inocu-
lated; 2. The reduction of cases of regular yellow fever to the
proportion of 6 per cent, instead of 19 per cent.; and 3. That of
fatal yellow fever to less than 1 per cent, instead of 15^ per cent.,
one single death from yellow fever having occurred among the
sixty-seven persons inoculated by us since 1881 until the present
date.
3. The contaminated mosquitoes appear to lose either par-
tially or completely their contamination after they have stung
healthy subjects; whereas the contamination appears to become
intensified by successive stings of the same insect on yellow fever
patients.
4. The inoculations performed during the colder season should
not be considered to afford sufficient protection, but should be
repeated on the approach of the hot season.
MEDICAL CLASSICS
vol. 2 March, 1938 no. 7
CONTENTS
Portrait of Ephraim McDowell ------ 642
/
Ephraim McDowell
Biography ----------- - 643
Writings - -- -- -- -- -- - 644
Bibliography of Biographies ------ 644
Three Cases of Extirpation of Diseased Ovaria.
Ephraim McDowell, M.D. - - - - - -651
Observations on Diseased Ovaria. Ephraim Mc-
Dowell, M.D. ---------- - 654
Portrait of James Marion Sims ------ 662
James Marion Sims
Biography ----------- - 663
Eponyms - -- -- -- -- -- - 665
Bibliography of Writings ------- 665
On Treatment of Vesico-Vaginal Fistula. James
Marion Sims - -- -- -- -- -- 677
MEDICAL CLASSICS
vol. ii March, 1938 no. 7
Ephraim McDowell
BIOGRAPHY
1771 Born November 11 in Rockbridge County, West Virginia,
the ninth of twelve children. He was of Scottish and
Irish ancestry. His father, Samuel McDowell, was a
member of the legislature of Virginia until he was ap-
pointed a judge and a land commissioner for Kentucky.
1783 Age 12. Family moved to Kentucky where Ephraim at-
tended the classical seminary of Messrs. Worley and
James at Georgetown, Kentucky.
1790 Age 19. Studied medicine with Dr. Humphreys of Staun-
ton, Virginia.
17 93 Age 22. Went to Edinburgh to study medicine under
John Bell and Alexander Monro, Secundus, among
others; did not receive a degree.
1795 Age 24. Returned to practice in Danville, Kentucky.
1800 Age 29. Sponsored a library in Danville.
1802 Age 31. Married Sarah Shelby, daughter of the first
governor of Kentucky, General Isaac Shelby, and had
eight children.
1807 Age 36. Given a diploma by the Medical Society of
Philadelphia.
1809 Age 38. Performed first ovariotomy in history, on Jane
Todd Crawford.
1812 Age 41. Operated on James K. Polk (later President), a
youngster of seventeen, for urinary calculus. '
1817 Age 46. Published first paper on ovariotomy. 'Three
cases of extirpation of diseased ovaria.
643
64.4 Medical Classics
1Z22 Age 51 - Traveled several hundred miles to Hermitage,
Tennessee, where he removed an ovarian tumor from
the wife of a close friend of Andrew Jackson, who
himself assisted with the operation. McDowell asked
$500.00 for a fee, but received $1500.00.
1825 Age 54. Given the degree of Doctor of Medicine by the
University of Maryland.
1830 Age 69. Died June 20, after a brief illness, possibly of
a gangrenous appendicitis.
One of the founders and a member of the first board of
trustees of Center College at Danville, Kentucky.
1879 The Kentucky State Medical Society erected a monument
over McDowell’s grave in McDowell Park, in Danville.
WRITINGS
1. Three cases of extirpation of diseased ovaria. The Eclectic
Repertory and Analytical Review, Medical and Philosophi-
cal, 7: 242-244, 1817.
2. Observations on diseased ovaria. Ibid., 9: 54 6-553, I 8 I 9-
BIBLIOGRAPHY OF BIOGRAPHIES
Biography in Lives of eminent American physicians and surgeons.
By S. D. Gross. Philadelphia, Lindsey and Blakiston, 1861.
8°, pp. 207-230.
Interesting incidents in the private life of Ephraim McDowell.
By J. P. Chesney. Cincin. Med. Report. 3: 133-136, 1870.
Biographical sketch. By J. D. Jackson. Richmond and Louis-
ville Med. Jour., 16: 642-650, 1873.
The first ovariotomy. A letter. By J. D. Jackson. Brit.
Med. Jour., 1; 467, 1874.
Memoir by J. H. Letcher. Tr. McDowell Med. Soc., Evansville,
Ind.,pp. 36-63, 1875.
ecrology By L. S. McMurtry. Tr. Amer. Med. Ass., 29 : 708-
712, 1878. 5 y '
Ephraim McDowell 645
Memorial oration in Danville, Ky., May 1 6, 1879, honor of
Ephraim McDowell, “The father of ovariotomy.” By S.
D. Gross. Louisville, Morton, 1879. 8°, 77 pp. Also,
abstr.: Med. Record, 15: 499-500, 1879.
Dedication of the monument to Ephraim McDowell. Cincin.
Lancet and Clinic, n.s. 2: 401-412, 1879.
The biography of Ephraim McDowell — ; together with valuable
scientific treatises and articles relating to ovariotomy, and
eulogistic letters from eminent members of the medical pro-
fession in Europe and America. By Mary Y. Ridenbaugh.
New York, C. L. Webster and Co., 1890. xvi, 558 pp., 3
pi., 22.5 cm. Same, 2 ed., rev. Philadelphia, the author,
1894. xvi, 624 pp., 19 port., 2 pi., 21.5 cm. Same, rev. ed.
New York, McDowell Pub. Co., 1897. xvi, 558 pp., 3 pi.,
22.5 cm.
Memorial address by L. S. McMurtry. Tr. South. Surg. and
Gynec. Ass., 1893, 6: 22-36, 1894. Also: Med. News, 64:
179-183, 1894.
Response to the toast, “Ephraim McDowell.” By J. Eastman.
Jour. Amer. Med. Ass., 25: 882-883, 1895.
Heroes of medicine. Practitioner, 58: 53— 56^ 1897.
Biography by J. H. Letcher. Amer. Pract. and News, 32: 6-8,
1901.
Biography by W. L. Lowder. Med. and Surg. Monitor, 4: 109-
112, 1901.
Biographical sketch. Columbus Med. Jour., 26: 586-590, 1902.
The passing of the historic McDowell building at Danville, Ky.
By W. L. Lowder. Physicians and Surgeons, 24: 241-258,
1902.
McDowell, the father of ovariotomy. By J. R. Goffe. Amer.
Jour. Obst., 59: 737-752, 1909. Also: Surg., Gynec. and
Obst., 8: 449-458, 1909.
A sequel to McDowell’s triumph, being a brief sketch of the rise
and progress of the Samaritan Free Hospital. By A. H. G.
Doran. Amer. Jour. Obst., 59: 75 2- 75 ^j 1909.
Biography by L. S. McMurtry. New York Med. Jour., 89: 933-
936, 1909.
646 Medical Classics
Ephraim McDowell in 1809. By S. M. Brickner. Tr. Amer.
Gynec. Soc. 34: 589-591, 1909.
The McDowell centenary celebration. By S. C. Swartsel (et
al.). Lancet-Clinic, Cincinnati, 102: 681-693, 1909.
Obituary by F. C. Warnshuis. Jour. Michigan Med. Soc., 8:
586-589, 1909.
Das Centennarium der Ovariotomie. By A. Martin. Monatsch.
f. Geburtsch. u. Gynak., 30: 675-696, 1909.
McDowell: the father of abdominal surgery. By G. Gellhorn.
Interstate Med. Jour., 17: 600-608, 1910.
Biography by S. C. Swartsel. Eclect. Med. Gleaner, Cincinnati,
n. s. 6: 97-106, 1910.
The indebtedness of posterity to the pioneer surgeon of the Mis-
sissippi valley. By J. D. Bryant. Louisville Month. Jour.
Med. and Surg., 18: 168-179, 1911.
Some facts not generally known regarding Ephraim McDowell.
By A. H. Barkley. Surg., Gynec. and Obst., 15: 496-503,
1912.
Biography by A. Schachner. Johns Hopkins Hosp. Bull., 24:
Ephraim McDowell; the ovariectomist. By G. Foy. Med.
Press and Circ., n.s., 102: 495, 1916.
Biographical sketch of McDowell. By J. D. Jackson. Ken-
tucky Med. Jour., 15: 11-17, 1917.
Dedicatory address (at unveiling of monument to Ephraim Mc-
Dowell). By S. D. Gross. Ibid., 15: 26-41, 1917.
Presentation address made in presenting Dr. McDowell’s door-
knocker to Dr. Gross. By R. O. Cowling. Ibid., 15: 41,
1917.
Address of Prof. Lewis A. Sayre at dedication of monument.
Ibjd., 15: 43, 1917.
Biography by L. S. McMurtry. Ibid., 15: 4 6, 1917.
p aim McDowell and J. Marion Sims, the American founders
of gynecology. U. S. Nav. Med. Bull., 14: 373, 1020.
Biography m Amer. Med. Biographies. (Kelly and Burrage)
Ephraim McDowell, Father of ovariotomy and founder of ab-
Ephraim McDowell 647
dominal surgery,” with an appendix on Jane Todd Craw-
ford. By A. Schachner. Philadelphia, Lippincott, 1921.
8°, xviii, 331 pp. Also, review by L. S. McMurtry. Surg.,
Gyncc. and Obst., 34: 696-697, 1922.
Sonic McDowell items. By J. Ruhrah. Med. Record, 101:
39 7, J 9 22 -
Short sketch of Dr. McDowell by 0 . Clark. Brazil-medico, 36:
305, 1922.
Master surgeons of America; Ephraim McDowell. By L. S.
McMurtry. Surg., Gyncc. and Obst., 36: 286-289, 1923.
Biography. Med. Jour, and Record, 123: 119-121, 1926.
Biography by \Y. P. Rhudy. Clifton Med. Bull., Clifton Springs,
12: 91-98, 1926,
Ephraim McDowell and ovariotomy. By I. S. Cutter. Inter-
nat. Abstract Surg., 47: 87-S9, 1928.
Address at unveiling exercises of statues of Dr. Ephraim Mc-
Dowell and Henry Clay. By R. Gilbert. Kentucky Med.
Jour., 27: 139-141, 1929.
Tribute to a southern physician, Ephraim McDowell. By T. W.
Moore. South. Med. Jour., 23: 1-6, 1930.
Ephraim McDowell (with his account of first operation for re-
moval of ovarian tumor). By E. Jclks. Jour. Florida Med.
Assoc., 16: 301-303, 1930.
Ephraim McDowell, the surgeon. By E. C. Cutler. New
England J. Med., 202: 276-278, 1930.
McDowell, pioneer and physician. By \V. G. Morgan. South.
Med. Jour., 24: 39-41, 1931.
Ephraim McDowell (with account of his operations for ovarian
cysts). By L. E. Burch. Ibid., 24: 36-39, 1931.
Biography by F. J. Underwood. Ibid., 24: 41-42, 1931.
McDowell; matured product of his labor. By G. A. Hendon.
Kentucky Med. Jour., 29: 3-8, 1931.
. Jane Todd Crawford; the model patient. By Mrs. P. E. Black-
erby. Ibid., 29: 8-10, 1 93 f .
Ephraim McDowell and early American surgery. By Iv. L.
Sicherman. Jour. Michigan Med. Soc., 30: 453-459, 1931.
648 Medical Classics
American physicians: Ephraim McDowell. Amer. Jour. Surg.,
15 : 5 S 6 > I 93 2 -
“Lest we forget.” By L. Frank. Ibid., 20: 1 60-1 66, 1933.
Surgeon of the wilderness. By W. D. Haggard. Surg., Gynec.
and Obst., 58: 415-419, 1934.
Jane Todd Crawford memorial Service. Kentucky Med. Jour,
(suppl.), 33: 3-36, 1935.
First ovariotomy performed by McDowell on Jane Todd Craw-
ford. By R. H. Jaffe. Wien, med Woch., 85: 1357-1358,
1935-
Biography by E. Podolsky. South. Surgeon, 5: 42-49, 1936.
Biography in Doctors on Horseback. By J. F. Flexner. New
York, Viking, 1937. pp. 121-162.
Ephraim McDowell and Jane Crawford. By G. A. Hendon.
Mississippi Doctor, 14: 14-20, 1937.
INTRODUCTION
Ephraim McDowell performed the first ovariotomy in 1809 but
he did not publish his experience until eight years later. In the
meantime, in 1813 and again in 1816, he had performed the opera-
tion a second and third time. Let us consider the several factors
which caused the delay in announcing this operation to the world.
Ephraim McDowell was born in the backwoods of America in
1771. After studying medicine with a practitioner in Virginia
for a short time, he went in 1793, at the age of twenty-two, to
Edinburgh for a formal medical course. There he came under
the influence of Alexander Munro, second, the anatomist, and
John Bell, the anatomist, surgeon and brother of Charles Bell.
In medical school McDowell was of course taught facts which
were believed in his day to be true. One of these beliefs held it to
be fatal to open a cavity of the body, especially the abdominal
cavity. No one recognized the relation between infection and
surgery in the abdominal cavity; it was seventy-four years before
Lister’s work on antisepsis. These dangers McDowell knew, but
he was also doubtless acquainted with the spaying of animals and
he may have known of the work of Houstoun of Edinburgh who
had tapped an ovarian cyst in 1701.
McDowell returned to America after two years of study in
Edinburgh and started practice in Danville, Kentucky. He be-
came the leading surgeon in that part of the country and traveled
hundreds of miles on horseback to attend his patients. But it
was not until fourteen years later, when he was thirty-eight years
of age, that McDowell’s greatest opportunity came to him. He
then was called in consultation to sec Mrs. Jane Todd Crawford
whom McDowell declared was suffering from an enormous ovarian
cyst although her two local doctors believed she was pregnant.
Mrs. Crawford could probably live only a year or two. McDowell
determined to give her the one chance of life and health by re-
moving the ovarian cyst. The facts were placed squarely before
the patient and she chose to accept the chance of surgical inter-
vention. McDowell insisted that the patient come to his home
in Danville sixty miles away where he could operate on her in the
best possible surroundings, with the best possible help and where
she would remain under his own supervision.
The story of this famous operation has been told dozens of times,
frequently and recently in a dramatic manner. (Read James
Thomas Flexncr: Doctors on Horseback, New York, Viking Press,
1937, pp. 121-162.) For our account we refer the reader to Me-
Dowell’s own report of the operation which is reproduced in its
entirety on the following pages. The operation was a complete
success. Mrs. Crawford lived thirty-one years longer and died
at the age of seventy-eight. .
One successful operation w r as not enough.. McDowell waited
until he had performed the operation for ovarian cy st three times.
He then decided to submit his results to the medical profession.
One copy of the paper which he wrote was sent to his old teacher,
John Bell, in Edinburgh. Bell was ill in Italy and never saw the
report. Another copy was sent to Dr. Philip Syng Physick,
“the father of American surgery,” who refused to have anything
to do with what he thought such an obvious impossibility. Mc-
Dowell then sent a copy of his paper to Dr. Thomas C. James,
Professor of Midwifery at the University of Pennsylvania. This
is the paper which reached publication and is to be seen on the
following pages.
Most doctors refused to give any consideration to McDowell’s
report. Others criticized it severely because they thought it con-
tained too little information on the physical findings, pathologic
specimens and operative technique. Nearly everyone thought
McDowell’s experience too fantastic.
Two years later McDowell wrote a second paper in which he
was able to report two additional cases of operation for diseased
ovana.
John Bell’s pupil, John Lizars, used McDowell’s paper in pub-
lishing his own observations on Extraction oj diseased or aria in
1825, without giving McDowell any credit. In the meantime, in
1821, Dr. Nathan Smith had performed an ovariotomy in Vermont
without knowing anything of McDowell’s work.
The brothers, Doctors John L. and Washington L. Atlee, of
Pennsylvania, recognized the value of McDowell’s contribution
and were early champions of his operation. Many years later
Charles Clay and Sir Spencer Welles of England as well as Auguste
Nelaton and Jules Pean of France performed the operation and
advocated it with enthusiasm.
McDowell s operation opened the way for all modern surgery of
the abdominal cavity. His teaching showed that an operation
within the abdomen was not necessarily fatal and from his experi-
ence there slowly began the modern surgery on all intra-abdominal
organs.
appeTdStf McD ° We11 Welf P r obably died of a gangrenous
Three Cases of Extirpation of
Diseased Ovaria
BV
EPHRAIM M ’DOWELL, M.D.
Dan?tUe 9 Kentucky
Published in The Eclectic Repertory, and Analytical Revlezr, Medical and Philosophical,
Philadelphia, 1817, Yol. VII
N DECEMBER 1809 , 1 was called to see a Mrs.
Crawford, who had for several months thought
herself pregnant. She was affected with pains
similar to labour pains, from which she could
find no relief. So strong was the presumption
of her being in the last stage of pregnancy,
that two physicians, who were consulted on her case, requested
my aid in delivering her. The abdomen was considerably
enlarged, and had the appearance of pregnancy, though the
inclination of the tumor was to one side, admitting of an easy
removal to the other. Upon examination, per vaginam, I found
nothing in the uterus; which induced the conclusion that it must
be an enlarged ovarium. Having never seen so large a sub-
stance extracted, nor heard of an attempt, or success attend-
ing any operation, such as this required, I gave to the unhappy
woman information of her dangerous situation. She appeared
willing to undergo an experiment, which I promised to perform if
she would come to Danville, (the town where I live) a distance of
sixty miles from her place of residence. This appeared almost
impracticable by any, even the most favourable conveyance,
though she performed the journey in a few days on horseback.
6s 1
6^2 Medical Classics
'With the assistance of my nephew and colleague, James
M’Dowell, M.D., I commenced the operation, which was con-
cluded as follows: Having placed her on a table of the ordinary
height, on her back, and removed all her dressing which might
in any way impede the operation, I made an incision about three
inches from the musculus rectus abdominis, on the left side,
continuing the same nine inches in length, parallel with the fibres
of the above named muscle, extending (p. 243) into the cavity of
the abdomen, the parietes of which were a good deal contused,
which we ascribed to the resting of the tumor on the horn of the
saddle during her journey. The tumor then appeared full in
view, but was so large that we could not take it away entire.
We put a strong ligature around the fallopian tube near to the
uterus; we then cut open the tumor, which was the ovarium and
fimbrious part of the fallopian tube very much enlarged. We
took out fifteen pounds of a dirty, gelatinous looking substance.
After which we cut through the fallopian tube, and extracted the
sack, which weighed seven pounds and one half. As soon as the
external opening was made, the intestines rushed out upon the
table; and so completely was the abdomen filled by the tumor,
that they could not be replaced during the operation, which was
terminated in about twenty-five minutes. We then turned her
upon her left side, so as to permit the blood to escape; after which,
we closed the external opening with the interrupted suture,
leaving out, at the lower end of the incision, the ligature which
surrounded the fallopian tube. Between every two stitches we
put a strip of adhesive plaster, which, by keeping the parts in
contact, hastened the healing of the incision. We then applied
the usual dressings, put her to bed, and prescribed a strict ob-
servance of the antiphlogistic regimen. In five days I visited
er, and much to my astonishment found her engaged in making
up er ed. I gave her particular caution for the future; and in
twenty-five days, she returned home as she came, in good health,
which she continues to enjoy.
Since the above case, I was called to a negro woman, who had a
hard and very painful tumor in the abdomen. I gave her mer-
sh?w° r Vvf 6 ° r /? ur monttls s °nie abatement of pain; but
she was still unable to perform her usual duties. As the tumor
Extirpation of Ovaria 653
was fixed and immovable, I did not advise an operation; though
from the earnest solicitation of her master, and her own distress-
ful condition, I agreed to the experiment. I had her placed upon
a table, laid her side open as in the above case; put my hand in,
found the ovarium very much enlarged, painful to the touch,
and firmly adhering to the vesica urinaria and fundus uteri. To
extract I thought would be instantly fatal; but by way of experi-
ment I plunged the scalpel into (p. 244) the diseased part. Such
gelatinous substance as in the above case, with a profusion of
blood, rushed to the external opening, and I conveyed it off by
placing my hand under the tumor, and suffering the discharge to
take place over it. Notwithstanding my great care, a quart or
more of blood escaped into the abdomen. After the hemor-
rhage ceased, I took out as clearly as possible the blood, in which
the bowels were completely enveloped. Though I considered
the case as nearly hopeless, I advised the same dressings, and the
same regimen as in the above case. She has entirely recovered
from all pain, and pursues her ordinary occupations.
In May 1816, a negro woman was brought to me from a dis-
tance. I found the ovarium much enlarged, and as it could be
easily moved from side to side, I advised the extraction of it.
As it adhered to the left side, I changed my place of opening to the
linca alba. I began the incision, in company with my partner
and colleague Dr. William Coffer, an inch below the umbilicus,
and extended it to within an inch of the os pubis. I then put a
ligature around the fallopian tube and endeavored to turn out the
tumor, but could not. I then cut to the right of the umbilicus,
and above it two inches, turned out a scirrhous ovarium, (weighing
six pounds) and cut it off close to the ligature, put round the fal-
lopian tube. I then closed the external opening, as in the former
cases; and she complaining of cold and chilliness, I put her to bed
prior to dressing her — then gave her a wine glass full of cherry
bounce, and thirty drops of laudanum, which soon restoring her
warmth, she was dressed as usual. She was well in two weeks,
though the ligature could not be released for five weeks; at the
end of which time the cord was taken away; and she now, with-
out complaint, officiates in the laborious occupation of cook to a
large family.
Observations on Diseased Ovaria
BY
EPHRAIM M’DOWELL, M.D.
Published in The Eclectic Repertory and Analytical Review, Medical end Philosophical ’
Philadelphia, 1819, Vo!. IX
dept. 1819 .
EAR SIR, I am induced to make this statement,
principally, in consequence of the observations
of Dr. Henderson, which appeared in a number
of the Repertory, published twelve or fifteen
months since; on ovarian disease, and abdom-
inal steatoma.
Since my former communication, I have mice performed the
operation of excision; which cases are subjoined.
I shall m the first place take some notice of the remarks of Dr.
1C , ener ’ b ) cb Hr. Henderson in his dissertation has thought
wort } o notice. The number of the Repertory, containing the
above mentioned remarks, I have unfortunately lost; but believe
_ * , r !^T ber m °? ° f his P rinci P al strictures. In the first
tion ta\h 1 Y 1 r V*’ the Doctor appears to take excep-
which"^ le T h °[ T the lnc5s5on > b 7 pointing out the sentence
the muscnl S 11 US) ™ ac * e an ’ nc ^ s ’ on about three inches from
same abou n- T ^T 50 " the left continuing the
measure the in^ ^ ^ lncbe s in length.” As I did not actually
said an incisin ^ ^ P erba P s > have been better to have
mutedu reZ "" * b ° Ut three inches to the left of the
OS pubis on a worn, “ S f TT the mar § in of the ribs to the
to an enormous size^H^rk d ? men , V as dlstend ed by a tumour,
mous size. He likewise objects to the parietes of the
654
Diseased Ovaria
655
abdomen being contused, in consequence of the tumour resting
on the horn of the saddle, during the patient’s journey to Dan-
ville. Observing that the “horn of the saddle is on the right side,
and the tumour was on the left.” Now, with all due deference
to the Doctor’s knowledge in surgery, and the structure of side
saddles , I think it would not be difficult to conceive, that a tu-
mour weighing upwards of twenty pounds, would fill the whole
abdomen, and although attached to the left ovarium, the weight
and bulk must have been almost, if not quite as great, on the right
side as on the left. I would observe, that my patient was a
woman of small stature; her abdomen had become so pendulous,
as to reach almost to her knees; the size of the tumor was ascer-
tained from actual weight. Had the left side of the abdomen
been contused, I would either have delayed the operation until
the contusion was removed, or operated on some other part. I
never have been of opinion, that bruised flesh would heal so
readily as sound; which matter I esteem of essential importance
to success in this operation. The Doctor also objects to another
assertion in this case, viz: “When I visited her on the fifth day,
I found her engaged in making up her bed.” The Doctor’s
scepticism, alone, appears to have carried him through the
statement, and I am surprised that he will even admit the fact
of her returning home, in five and twenty days after the opera-
tion, on horseback; a distance of seventy miles, and in the depth
of winter.
Dr. Henderson thinks I was entirely too inconsiderate in my
detail of the cases of diseased ovaria; I thought my statement
sufficiently explicit to warrant any surgeon’s performing the
operation when necessary, without hazarding the odium of mak-
ing an experiment; and I think my description of the mode of
operating, and of the anatomy of the parts concerned, clear
enough, to enable any good anatomist, possessing the (p. 548)
judgment requisite for a surgeon, to operate with safety. I hope
no operator, of any other description, may ever attempt it. It
is my most ardent wish, that this operation may remain, to the
mechanical surgeon, for every incomprehensible. Such have been
the bane of the science; intruding themselves into the ranks of
Medical Classics
the profession, -with no other qualification but boldness in under-
taking, ignorance of their responsibility, and indifference to the
lives of their patients; proceeding according to the special dic-
tates of some author, as mechanical as themselves, they cut and
tear with fearless indifference, utterly incapable of exercising any
judgment of their own cases of emergency; and sometimes, with-
out possessing even the slightest knowledge of the anatomy of the
parts concerned.
The preposterous and impious attempts of such pretenders,
can seldom fail to prove destructive to the patient, and dis-
graceful to the science. It is by such this noble science has been
degraded in the minds of many, to the rank of an art.
No case of diseased ovaria has come under my observation,
similar to the one described by Dr. Henderson. The tumours
extracted by myself, I have kept by me, in a state of preservation;
they have been submitted to the inspection of most, if not all the
physicians who have visited me. Their opinions, as to the na-
ture of the disease, have all accorded with my own. In our
most scrupulous examinations, we were never able to discover
any portion of the tumours to be of a natural or healthy structure;
the whole exhibition was that of a morbid undistinguishable mass,
which myself and others of the faculty, who were present at the
operations, were of opinion, had once been the natural ovaria;
in as much as no ovarium remained on the side from whence the
tumour was extracted. This was as clearly evident as it could
have been on dissection after death; my incisions were made so
free and extensive, that I have always performed every part of
this operation by sight.
Such ovaria as I have described as dropsical, contained a gelat-
inous fluid in a sac about half an inch in thickness, and of a
spongy texture; such as I have denominated schirrus, were of a
spongy t<
fected wii
affected;
the pains
attended
weight in
-xture tnroughout, and somewhat elastic. Those af-
th schirrus, complained of lancinating pains in the parts
which, from their description, were similar (p. 549) to
' ’ n , ot ^ er schirrous glands. The dropsical ovaria, are
f j ^ P a * n > anc ^ produce a most oppressive sense of
e a omen. By these symptoms, and by a nice sense
Diseased Ovaria 657
of touch, the species may generally be distinguished from one
another. How to distinguish them from steatoma and other
affections which those organs are liable to, I shall not pretend to
define, nor, in the present state of knowledge, do I think it at all
necessary; nor even the distinction from one another.
Excision I esteem less perilous than any other mode of treat-
ment; and the only certain cure for either of them. For schirrus
and steatoma, no other relief, within our knowledge, is
practicable.
The dropsical ovaria may be relieved by tapping with a large
trocar. But the relief is only temporary, and would be attended
with no inconsiderable danger. Some further reasons for my
aversion to the trocar, I will relate hereafter.
The second case in which I operated for diseased ovaria, was
the case of a negro woman in this neighbourhood. On exposing
the tumour (as related in the Repertory, Vol. VII.) it adhered so
firmly to the neighbouring parts, that I did not attempt its ex-
traction, but made a free incision into it with the scalpel, and dis-
charged its contents; she recovered of the operation, and I
thought her well of the disease; but, she informed me some short
time since, that it had been growing for the last twelve or eight-
een months, and says it is now, about the size it was when I
opened her six years ago.
None of my patients have been able to give me any satisfactory
account as to the origin of the disease; with some it commenced
some months after delivery. The first supposed herself preg-
nant, and went on to make the necessary preparation for her
lying-in; the time for her delivery being protracted to a great
length, and her anxiety and doubts increasing, I was called in,
and immediately, on examination, per vaginam, found she was
not with child.
Case I
In April, 1817, I operated on a negro woman from Garard
county; extracting a schirrous ovarium, weighing five pounds,
(p. 55°) The incision was made near the linea alba; as in cases
formerly related, I tied a cord firmly round the ligament attach-
6^8 Medical Classics
ing it to the uterus, and cut away the ovarium; but owing to the
shortness and sponginess of the part, the cord clipped off, before
I laid the ovarium out of my hands, and a profuse discharge of
blood took place. I immediately drew the uterus to the external
incision, and commenced tying up the bleeding mouths sepa-
rately. This also, in consequence of the diseased state of the
parts, proved only of partial efficacy, as several of the ligatures
cut through, on tying them. I now thought it all over with
my poor patient, but arming a needle with a strong ligature, I
passed it round the ligaments; securing it in its place by taking
several stitches over its surface as I passed it round, and firmly
tied it. By turning her nearly on her stomach, I was able to get
most of the blood out of the abdomen, using my hand to extract
the coagulated portion. The incision was then closed by the
interrupted suture, and strips of adhesive plaster. She recovered
happily; but, I am told her health is not good; the account I had
of her was awkwardly given ; from what I could learn, her com-
plaint is hysterical. This, though the smallest ovarium I have
ever extracted, was much more troublesome to the patient, than
in any previous case. Besides experiencing severe lancinating
pains in the parts, she was seldom able to discharge her urine,
without getting almost on her head, in consequence of the tumour
falling down into the pelvis, and compressing the urethra.
, Case II
A negro woman from Lincoln county, was brought to me in
April, 1818, supposed, by the different physicians who had at-
tended her, to be affected with ascites; she had been under their
care about eighteen months. On examining her, I could very
plainly discover the fluctuation of fluid in the abdomen, and for
some months administered medicines for ascites, without effect;
espairing of the power of medicines, I at length tapped her, and
discharged thirteen quarts of gelatinous fluid, such as I had be-
ore met with in dropsical ovaria, of so thick a consistence, that
oun it extremely difficult and tedious to discharge it. In
two months after, I found it necessary to tap (p. 551) again;
Diseased Ovaria 659
during the process of discharging it a second time, the opening
was frequently stopped by viscid portions of the jelly, which were
broken by introducing a probe; when the abdomen was pretty
well evacuated, I discovered, with the probe, a firm substance,
which, on minute examination, I found to be of considerable size.
I at once supposed the existence of a dropsical ovarium, in which
I was confirmed, on finding the uterus empty by examination per
vaginam. Some months after she was again tapped; at which
time, I made the opening large enough to admit my finger; by
which means, I was able to ascertain the nature of the disease
beyond a doubt. I informed her master what was certainly her
situation, and that nothing but excision could affect a cure. My
advice was not immediately followed, nor until after she was
tapped a fourth time; a week or two after which, she was brought
to Danville, to undergo the operation, which was performed
May 11, 1819. The diseased ovarium being on the left side, and
evidently dropsical; the incision was of course made on the left
side. On exposing the tumour, it was found to adhere to the
parietes of the abdomen; and to the intestines, by slender cords
which were easily separated with the hand, and which caused a
slight effusion of blood. To the uterus, two strong ligaments
adhered; one, the natural ligament, attaching the ovarium to the
uterus, the other, an artificial one, attached to the fundus uteri:
which appeared, to be composed of the above mentioned slender
cords, compacted together. I then tied fine cords of silk firmly
round each of these ligaments, discharged the contents of the
tumour, and cut it away.
There were sixteen quarts of gelatinous fluid discharged from
the tumour and abdomen. The dressings and precautions were
the same as in other cases. The second day after the operations,
she was affected with violent pain in the abdomen; together
with an obstinate vomiting. She was blooded as copiously as
her strength would allow, but without producing any abatement
of the pain or vomiting. On the third day she died. On ex-
amination after death, the uterus, contrary to expectation, ap-
peared natural and uninflamed, the right ovarium healthy, the
66o Medical Classics
silken cords were securel)', and properly fixed, and not in a situa-
tion likely to injure the adjoining parts. Her (p. 55 2 ) d eat; h had
proceeded from peritoneal inflammation. This membrane,
throughout its whole extent, appeared greatly inflamed, and the
intestines largely inflated.
I was assisted in this operation by my nephew, Dr. William
A. M’ Dowell. Doctors Weizegar, Tomlinson, and Horr were
present.
On examining the substances we had removed, the contents
of the sac presented a variety; different portions of the fluid
were of different colours: semitransparent, white, brown, and
yellow. There was also contained in the sac, a considerable
quantity of hair; which grew from the inner surface. Enveloped
in the inner substances of the sac, we found a bone, resembling,
very much, in shape, the front tooth of a cow.
From the circumstance of the hair and bone, one or two of the
physicians present, were inclined to believe the disease originated
from an extra uterine conception; and that all of the foetus had
been absorbed, save the hair, and single bone, which was found.
This question I submit to the faculty. As for myself, I think it as
reasonable to suppose, the hair and bone in this unnatural situa-
tion, was the result of a morbid action. She had been delivered
of a child two years before the operation, her health during that
time was never good, but she had no reason to believe herself
pregnant; and if it were the case, I doubt whether a whole foetus
could be so nearly absorbed in two years. There ivas likewise a
round hole in the sac, which, from the levelled appearance of its
edges, appeared of long standing; the hole was about the size of a
musket ball. And there is no doubt, that the gelatinous fluid
escaped through this aperture into the abdomen. This ovarium,
when brought into view, was of a large size; which is the more
Te ?! Z ? , a , ’ w hen we consider the enormous quantity of fluid
w ic a been drawn off at different times, by the operation of
paracentesis abdominis. During the evacuation, a bandage was
ept oun tig tly round the abdomen; and considerable pres-
sure was made with the hands, in order to evacuate its whole
Diseased Ovaria
66 1
contents. In an attempt to draw off the contents of such a tu-
mour with the trocar, it would be impossible to perforate all the
vesicles;* and such only, as were (p. 553) pierced, would dis-
charge their contents. While one portion of the vesicles of the
ovaria would discharge themselves into the abdomen, another
portion would remain diseased in the original way. Thus com-
pounding in the system, two of the most deplorable diseases to
which it is liable.
EPHRAIM M’ DOWELL.
Dr. James.
* That this is the structure of diseased ovaria, I infer, both from authorities, and from
the difficulty in discharging their contents. I have always been under the necessity of
introducing my hand, and raking it forth; the obstacle to the discharge being always a
membranous structure.
James Marion Sims
BIOGRAPHY
1813 Born Jan. 25, in the Hanging Rock Creek Section of
Lancaster County, South Carolina.
1 832 Age 1 9. Was graduated as Bachelor of Arts from College
of South Carolina. Began study of medicine in office
of Dr. G. Churchill Jones, of Lancaster, S. C.
1834 Age 21. Attended his first series of lectures in medicine
at Medical College of Charleston, S. C.
1835 Age 22. Was graduated from Jefferson Medical College,
Philadelphia. Began practice of medicine in Lancaster,
S. C., later moved to Mount Meigs, Alabama.
1836 Age 23. Married Theresa Jones, a niece of Dr. G.
Churchill Jones, and had 7 children.
1840 Age 27. Moved to Montgomery, Alabama.
1845 Age 32. First began work on vesicovaginal fistula.
1851 Age 38. Taken ill with dysentery. Traveled north for
health.
1852 Age 39. Described the position now known by his name
and an operation for vesicovaginal fistula.
1 853 Age 40. Moved to New York, Madison Ave. and 29th
St.
1855 Age 42. Founder of a hospital for women at 83 Madison
Ave. in New York City. In 1857 this became the
Woman's Hospital of the State of New York.
1861 Age 48. For political reasons during Civil War moved
to Europe where he lived in London and Paris for six
years. Warmly received by leading physicians and
surgeons, before whom he repeatedly performed his
operation for vesicovaginal fistula.
663
664 Medical Classics
!
1868 Age 55. Made Governor and Senior Consulting Surgeon
of Woman’s Hospital, New York.
1870 Age 57. Surgeon-in-Chief of Anglo-American Ambulance
Corps in Franco-Prussian War.
187a Age 59. Member of Board of Surgeons, Woman’s Hos-
pital.
1874 Age 61. Resigned from Woman’s Hospital because out-
siders were stopped from visiting his clinics and cancer
patients were refused admission. Shortly before his
death he became member of the consulting board.
1876 Age 63. President of American Medical Association.
1880 Age 67. President of American Gynecological Society.
1881 Age 68. Attended President Garfield after the attempted
assassination. 1
1883 Age 70. Died Nov. 13, quietly and painlessly in bed.
Buried in Greenwood Cemetery, New York City.
(1894) European and American admirers erected a statue to
his memory in Bryant Park, New York City. In 1936
t is statue was removed to Fifth Avenue at 103rd
treet, opposite the New A ork Academy of Medicine.
pj!° W ° f f ^ ^°J al A wdemy of Medicine in Brussels.
Fellow of the Obstetrical Society of London.
^Tralc^ ° f ^ KnlghtS ° f the Le g 5on of Honor from
Received the Iron Cross from Germany.
Received the Order of Leopold I from Belgium
HoLaJyretbIroftheETr'TR”' 31 , 1 '’ Spai "- Portu 8 al -
Paris and Dublin medical “odcti ™ ’ BCrli "’ ChriStiania ’
MembCT of A l NewyTk S U M \f Cal Association -
Member of Z New ?“? Med 'f ' S ° d ^
“"i^ ^ Pthol^cal and Surgi-
665
James Marion Sims
EPONYMS
Depressor; A loop of stout wire used in depressing the anterior
vaginal wall in examinations.
Method: Of treating trismus nascentium.
Operation: For vesicovaginal fistula.
Position: The semiprone position; patient on the left side and
the chest, the right knee and thigh drawn up, the left arm
along the back.
Speculum: A form of duck-billed vaginal speculum.
Suture: A shotted or clamp suture.
BIBLIOGRAPHY OF WRITINGS
1. Double congenital hare-lip — absence of the superior incisors,
and their portion of alveolar process. Amer. Jour. Dental
Sc., 5: 51-56, 1844.
2. On the extraction of foreign bodies from the meatus audito-
rius externus. Amer. Jour. Med. Sc., 9: 336-342, 1845.
2. Trismus nascentum, its pathology and treatment. Ibid.,
II: 363-379, 1846. Also: Philadelphia, Lea and Blanch-
ard, 1864. 8°, 21 pp.
4. Removal of the superior maxilla for a tumor of the antrum.
Apparent cure. Return of the disease. Second opera-
tion. Sequel. Amer. Jour. Med. Sc., 13: 3 10-3 14, 1847.
5. Osteo-sarcoma of the lower jaw. Removal of the body of
the bone without external mutilation. Ibid., 14: 37 °~ 373 >
i847- . ....
6. Further observations on trismus nascentium, with cases
illustrating its etiology and treatment. Ibid., 16: 59 ” 7 ^?
354-366, 1848.
7. On the treatment of vesico-vaginal fistula. Ibid., 23: 59-
82, 1852. Also, rev.: New York Med. Times, p. 104, 1853.
Also: New York, 1853. 8°, 28 pp. Also: Philadelphia,
Lea and Blanchard, 1853- 8 °, 28 pp.
8. Two cases of vesico-vaginal fistula, cured by J. Marion 1ms
of New York, late of Montgomery, Alabama. New York
Med. Gaz., 5: 1-7, 1854. ,
9. A case of vesico-vaginal fistula, with the os uteri c ose up in
the bladder; cured by J. Marion Sims of New York, late
666 Medical Classics
of Montgomery, Ala., with an illustration exhibiting the
parts. Amer. Med. Monthly, 1: 109-112, 1854.
10. Report on Dr. Sim’s lecture for a Woman’s Hospital. Ibid.,
479-480, 1854.
11. A case of vesi co-vaginal fistula resisting the actual cautery for
more than seven years; cured in thirteen days by the
author’s process. New York Med. Times, 3: 265-257,
1854. Also, abstr.: Amer. Jour. Med. Sc., 28: 283 only,
1854 .
12. A new uterine elevator, with illustration. Ibid., 35 : 132-134,
1858.
13. A review of silver sutures in surgery. An anniversary dis-
course before the New York Academy of Medicine, Nov.
18, 1857. New York, Wood, 1858. 8°, 7 9 pp. Also:
New York, Wood, 1858. 20 pp. Also, rev: North Ameri-
can Med. and Surg. Rev., 2: 635-653, 1858. Also: New
York Acad. Med. Anniversary Discourses, Vol. 1.
14. Amputation of the cervix uteri. Tr. New York State Med.
Soc., pp. 367-371, 1861. Also: New York, 1861. 8°,
16 pp.
I 5 - Vaginismus. Amer. Med. Times, 4: 310-311; 317-318, 1862.
Also, abstr.: Med. Times and Gaz., 2: 517 only, 1861.
Also, abstr.: Lancet, 2: 477 only, 1861.
16. On the method of uterine examination. Ibid., 2: 413-416,
1864.
17. Uterine polypi. Ibid., 457-458; 542-544; 627-628, 1864.
Speculum. Ibid., 501-502, 1864.
18. Influence of uterine displacements upon the sterile condition.
Med. Times and Gaz., 2: 208-209, 1865. Also, abstr.:
Amer. Jour. Med. Sc., 50: 557-558. 1865. Also, abstr.:
Brit. Med. Jour., 2: 190 only, 1865.
19. Painful menstruation. Lancet, I: 224-225; 253-254; 338-
3395 587-588; 2: 42 only, 1865.
20. Dilatation or division of the cervix uteri. Ibid., 1 : 44 0-44 1,
21. Chronic inversion of the uterus. Brit. Me'd. Jour., 2: 54I
on y, 1865. Also, abstr.: Med. Times and Gaz., 2: 537
only, 1865. Also, abstr.: Lancet, 2: 538 only, 1865.
James Marion Sims 667
11 . Procedentia uteri. Abstr. Lancet, 2: 677-678, 1865. Also
abstr.: Brit. Med. Jour., 2: 666-667, 18 65. Also, abstr.!
Amer. Jour. Med. Sc., 51: 554-555, 1866.
a 3 * Clinical notes on uterine surgery; with special reference to
the management of the sterile condition. Lancet, 1: 17—
20; 74-78; 114-115; 214-218; 263-265; 418-420, 1865.
Rev., Ibid., 1: 125-126, 1866. Also: New York, Wood,
1866. 8°, 401 pp. Also: London, Hardwicke, 1866. 8°,
viii, 436 pp. Also: Klinik der Gebarmutterchirurgie mit
besonderer Berucksichtigung der Behandlung der Sterili-
tat. Deutsch brsg. von Hermann Beigel. Erlangen.
Enke, 1866. 8°, xiii, 333 pp. Also: Notes cliniques sur
la chirurgie uterine dans ses rapports avec le traitement de
la st£rilite. Traduites de l’Anglais par le Dr. Lheritier.
Paris, Masson, 1866. 8°, vi, 500 pp. Also: New York,
Wood, 1867. 8°, xi, 401 pp. Also: New York, Wood,
1869. Also: In German. 2 Aufl., Erlangen, Enke, 1870,
8°, xi, 352 pp. Also: New York, Wood, 1871. 8°, xi,
401 pp. Also: New York, Wood, 1873. Also: In Ger-
man, 3 Aufl., Erlangen, Enke, 1873. 8°, xii, 362 pp.
Also: New York, Wood, 1886.
24. Ovariotomy. Pedicle secured by silver wire, after the fail-
ure of the actual cautery to arrest hemorrhage. Brit. Med.
Jour., 1 : 50-51, 1867. Also, Abstr.: Amer. Jour. Med. Sc.,
53: 548-550, 1867.
25. On the nitrous oxide gas as an anesthetic. Brit. Med.
Jour., 1:349-350, 1868.
26. Illustrations of the value of the microscope in the treatment
of the sterile condition. Ibid., 205 only; 465— 466, 492-
494, 1868.
27. The Woman’s Hospital Anniversary. Address delivered at
the Woman’s Hospital, New York, Nov. 17, 1868. New
York, Baker and Godwin, 1868. 11 pp.
28. On the microscope as an aid in the diagnosis and treatment of
sterility. New York Med. Jour., 8: 393 ~ 4 I 3 > i86 9 - Also:
New York, Appleton, 1869. 8°, 25 pp.
29. Ovariotomy. Pedicle secured by silver wire. Ligature.
Cure. Brit. Med. Jour., 1: 3*6 only, 1869.
568 Medical Classics
30. Anglo-American ambulance. London, Harrison and Sons,
1870. 8°, 20 pp. .
31. Kennedy’s concentrated extract of pinus canadensis. Med.
Gaz., 7: 69-70, 1871.
32. On ovariotomy. New York Med. Jour., 16: 561—617} 1872;
i 7 : 360-387, 1873. Also: New York, Appleton, 1873.
8° } 85 pp. (Same) Ueber Ovariotomie. Deutsch von
Hermann Beigel. Erlangen, F. Enke, 1873. 1 p. i*>
io 5 PP-
33. Nelaton’s method of resuscitation from chloroform narcosis.
Brit. Med. Jour., a: 239-241, 1874. Also, abstr.: Amer.
Jour. Med. Sc., 68: 570-573, 1874.
34. On intra-uterine fibroids, with illustrations of methods, etc.
New York Med. Jour., 19: 337-360, 1874. Also: New
York, Appleton, 1874. 8°, 27 pp. (Same) Tumores
fibrosos intra-uterinos. Trad, al espanol por Agustin
Danssa. Barcelona, N. Ramirez y Ca., 1875. 8°, 29 pp.
35. Utero-gastrotomy. Med. Rec., 10: 107-108, 1875. Also,
abstr.: Amer. Jour. Med. Sc., 69; 582-583, 1875.
36. Lecture on vesico-vaginal fistula. Pac. Med. and Surg.
Jour., 1875. Also: Med. Herald, Leavonworth, 1875.
37. Legislation and contagious diseases. Address as President
of the American Medical Association, Jan. 6, 1876. Trans.
Amer. Med. Ass., 27: 91-m, 1876. Also, ext.: Phila-
delphia, Collins, 1876. 8°, 14 pp. Also: London, Spot-
tiswoode, 1876, 8°, 28 pp. Also, ext.: London, Spottis-
woode, 1876, 8°, 16 pp.
38. Epithelioma of the cervix uteri. Abstr.: Brit. Med. Jour, 2:
277 only, 1876.
39- The Woman’s Hospital in 1874. A reply to the printed
circulars of Dr. E. R. Peaslee, T. A. Emmett, and T. Gail-
lard Thomas s address to the medical profession. May 5>
1877. New York, Kent and Co., 1877. 8°, 24 pp.
40. The discovery of anesthesia. Richmond Med. Monthly, 4:
1877. Also: Richmond, J. W. Ferguson & Co., 1877.
20 pp. Also: Richmond, 1877; New York, 1879. 8°,
14 pp.
James Marion Sims 669
41. Professor Listers Introduction on antiseptic surgery. Brit.
Med. Jour., 2: 608-609, 1877.
42. Battey’s operation. Ibid., 2: 793-794, 840-842, 881-882,
916-918, 1877. Also: London, 1878. 8°, 31 pp. Also,
ext.: London, 1878, 8°, 2 pp. ' ’
43. Sterility in women. Johnson’s Cyclopaedia, 1877.
44. Obituary. Gustav Simon. Amer. Jour. Obst., 10: 80-83,
1877. Also: New York, 1877. 8°, 7 pp.
45> Cholecystotomy for the removal of gall-stones in dropsy of
the gall-bladder. Brit. Med. Jour., 1: 811-815, 1878.
Also: London, 1878. 12 0 , 20 pp. Also: Gaillard’s Med.
Jour., 1878. Also, in French: Rev. de Lit. Med. pour
1878. 3: 564, 1878; 4: 34; 78; 107; 250; 278-280; 400-402;
1879. Also, in French: J. de med. chir. et pharmacol.,
Brux., 68: 418-424; 499-510, 1879.
46. The operations of Simpson and Sims for stenosis of the cervix
uteri compared. Abst.: Brit. Med. Jour., 2: 365-366,
1878. Also: Gaillard’s Med. Jour., 1878.
47. Surgical instruments exhibited at International Exhibition in
Paris: uterine curette, bistoury holder, uterine dilator.
Brit. Med. Jour., 2: 704-705, 1878.
48. On the extraction of foreign bodies from the ear. Ibid.,
282; 868-869, 1878.
49. On the surgical treatment of stenosis of the cervix uteri.
Tr. Amer. Gyn. Soc. 1878, 3: 54-100, 1879.
50. History of the discovery of anesthesia. Virginia Med.
Monthly, 1879. Also: Gaillard’s Med. Jour., 1879. Also:
New York, 1879. 8°, 14 pp.
51. On syringing the ear. Letter. Brit. Med. Jour., 1 : 140 only,
1879.
52. A forceps case. Letter. Ibid., i: 282 only, 1879.
53. Diagnosis of abscesses of the liver by symptoms of cerebral
hyperaemia, with some remarks on the treatment of he-
patic abscess by aspiration. Trans. Virginia Med. oc.,
3: 106-1 1 1, 1879. Also; Southern Practitioner, 2: 97-103*
1880. Also: Richmond, 1879. 8°, 6 pp. .
54. The treatment of epithelioma of the cervix uteri. Amer.
^TcdiCcil Classics
Jour. Obst., 12: 451-489, 1879. Also: Gaillard’s Med.
Jour., 29: 625-643, 1880. Also: New York, Wood, 1879.
8°, 41 pp. Also, in French: Ann. de gynec., Par., 13: 401-
42a, 1880.
The bromide of ethyl as an anesthetic. New York Med.
Rec., 17: 361-365, 1880. Also, abstr.: Brit. Med. Jour.,
i: 746 only, 1880. Also: Gaillard’s Med. Jour., 29: 530-
546, 1880. Also: New York, 1880. 8°, 22 pp.
56. Thomas Keith and ovariotomy. Surgeons in public journals.
Amer. Jour. Obst., 13: 290-303, 1880. Also: Med. Rev.,
New York, 17: 103, 1880. Also: New York, Wood, 1880.
8°, 16 pp.
57. Pregnancy vomiting. Arch. Med., 3: 269-276, 1880. Also:
New York, Putnam, 1880. 8°, 8 pp. Also: Gaillard’s
Med. Jour. 1880.
58. Annual address as President of the American Gynecological
Society. Trans. Amer. Gyn. Soc., 5: 25-37, 1881. Also:
Gaillard’s Med. Jour., 5, 1881.
59. Remarks in W. O. Baldwin’s On the poisonous properties of
quinine. Med. Gaz., Oct. 22, 1881.
60. Remarks on the treatment of gunshot wounds of the abdomen
in relation to modern peritoneal surgery. Brit. Med.
Jour., 2: 925-926; 971-973, 1881 ; i: 184-186; 222-223;
260-262; 302-304, 1882. Also: Gaillard’s Med. Jour.,
1882.
61 . The surgical treatment of President Garfield. North Ameri-
can Rev., New York, 133: 594-601, 1881.
62. Treatment of syphilis. Brit. Med. Jour., i: 448-450, 1S83.
Also: Indianapolis, 1883. 8°, 7 pp. (Same) 2. ed., In-
dianapolis, 1883. 8°, 7 pp.
63. The story of my life. Edited by his son, H. Marion Sims,
M. D. New York, Appleton, 1884. 12°, 47 i pp. Also:
JNew York, Appleton, 1885. 8°, 471 pp. Also: New
York, Appleton, 1888. 8°, 471 pp.
by i
James Marion Sims
BIBLIOGRAPHY OF BIOGRAPHIES
Ode to Dr. Marion Sims. By H. L. Med. Times and Gaz., i :
cu6, 1866.
Biography. Richmond and Louisville Med. Tour., ic: qa-nr
1873. 95,
Biography by H. L. Stuart. Virginia Med. Month., 3: 731-743,
1877.
To the medical profession. Statements respecting the separation
of Dr. J. Marion Sims from the Woman’s Hospital, New
York. By E. R. Peaslee, T. A. Emmett and T. G. Thomas.
(Reply to Sim’s pamphlet entitled “The Woman’s Hospital
in 1874.”) New York, 1877.
Editorial interview with Dr. J. Marion Sims; a full exposition of
the points in the controversy between Drs. Peaslee, Emmet
and Thomas and Dr. Sims. By W. Hazard. St. Louis
Clin. Rec., 4: 153-172, 1877.
Dr. Marion Sims and his operations in Vienna. By F. Barker.
Med. Rec., 14:376, 1878.
Biography in Physicians and Surgeons in the United States.
Edited by W. B. Atkinson. Philadelphia, Robson, 1878,
pp. 48-49.
Biography. Boston Med. and Surg. Jour., 109: 501, 1883.
Biography. New York Med. Jour., 38: 550, 1883.
Biography. Jour. Amer. Med. Ass., 1 : 659, 1883.
Biography. Med. News, 43: 555 ? *883.
Biography. Med.-Leg. Jour., 1: 471, 1883-4.
Biography. Med. Rec., 24: 557 ? 1 B83.
Biography. Virginia Med. Month., 10: 631-638, 1883-4.
Biography. Gaillard’s Med. Jour., 36: 601-604, 1883.
Biography. Brit. Med. Jour., 2: 995, 1883.
A memoir of J. Marion Sims. By T. A. Emmet. New York
Med. Jour., 39: 1-5, 1884. Also: New York, Appleton,
1884. 8°, 19 pp. ,, . ,, ,
Biography by F. Howitz. Gynaek. og obst. Medd., Kj^benh.,
5: 1-3, 1884. ,
Biography by P. F. Munde. Amer. Jour. Obst., 17: 52-61, 18 4 -
672
Medical Classics
Tribute to the late James Marion Sims. By W. O. Baldwin.
Gaillard’s Med. Jour., 37: 1-9, 1884. Also: Montgomery,
Ala., 1884. 8°, 31 pp. _ .
Biography by W. M. Carpenter. Tr. Med. Soc. New York, pp.
400-405, 1884.
In memoriam. Eulogy pronounced at the funeral of J. hlarion
Sims, November 16, 1883. By Rev. Charles Parkhurst.
New York, Putnam, 1884. 12 0 , 16 pp.
The story of my life. Edited by his son, H. Marion Sims, M.D.
New York, Appleton, 1884. 12 0 , 471 pp. Also: New York,
Appleton, 1885. 8°, 471 pp. Also: New York, Appleton,
1888. 8°, 471pp.
Biography by J. M. Toner. Gaillard’s Med. Jour., 32.: 127-134,
1884.
Biography by W. G. Wylie. New York Med. Jour., 39: 405;
432, 1884. Also: New York, 1884. 8°, 26 pp.
Biography. New England Med. Month., 4: 204-207, 1884.
Biography by E. Vande Warker. Tr. Amer. Gynec. Soc., 1884,
9 : 398-403, 1885.
Biography by J. S. B. Tr. Amer. Surg. Ass., 1884, 2: xxxviii,
1885.
In memoriam. By W. M. Carpenter. New York, Stettiner,
Lambert and Co., 1886. 8°, 18 pp.
Biography. Med. Mirror, I: 469-471, 1890.
Reminiscences of J. Marion Sims; incidents of his early profes-
sional life; discovery of his speculum; peculiarities. By
T. A. Means. Alabama Med. and Surg. Age, 6: 607—616,
1893-4..
J. Marion Sims, the father of modern gynecology. By P. F.
Munde.. Med. Rec., 46: 514, 1894.
J. Marion Sims, surgeon and philanthropist. By G. F. Shrady.
Ibid., 513, 1894.
The Sims memorial statue. Amer. Jour. Obst., 30: 712-720,
1894.
Reminiscences of J. Marion Sims in Paris. By E. Souchon.
Med. Rec., 46: 705-708, 1894. Also: Texas M. J., 10:
James Marion Sims
673
399 4 ° 5 > *894-5. Also: Tr. South. Surg. & Gynec. Ass.,
1894, 7: 27-38, 1895.
Places rendered famous by Marion Sims, in Montgomery, Ala.;
notes on a trip to the meeting of the American Surgical
Association in New York, May 1895. By E. Souchon.
New Orleans Med. and Surg. Jour., 23: 455-460, 1895-6.
Also: New Orleans, 1896. 8°, 18 pp.
J. Marion Sims and his work. By J. A. Wyeth. Med. Rec., 48 :
694-700, 1895. Also: Tr. South. Surg. & Gynec. Ass., 1895,
8:9-39,1896.
Ueber Marion Sims und seine Verdienste um die Chirurgie. By
R. Olshausen. Berlin, 1897. 8°, 30 pp.
Biography. Practitioner, Lond., 60: 61-54, 1898.
The life and work of J. Marion Sims. By W. D. Ward. Amer.
Jour. Obst., 54: 192-203, 1906.
Biography. A historic parallel. By G. M. Gould. Biog.
Clinics, 5: 383-388, 1907.
Biography by J. H. Allen. J. South Carolina Med. Ass., 7 : 43-
47, 1911.
Biography by W. L. Lowder. Charlotte, N. C., Med. Jour., 66:
93-101, 1912.
Biography by C. Cleveland. Amer. Jour. Obst., 67: 954 ~ 955 >
1
Biography by A. Martin, Monatschr. f. Geburtsch. u. Gynaek.,
37: 217, 1 91 3, Also: Zeitschr. f. Geburtsch. u. Gynaek.,
73: 946-948, 1913.
Biography by A. Allemann. Miinchen. med. Woch., 60: 138,
1 j.
Biography. Album Amer. Gynec. Soc., p. 442., 1918.
Ephraim McDowell and J. Marion Sims, the American founders
of gynecology. United States Nav. Med. Bull., H- 373 >
I 92°. Tijrj A
Sketch of life. By J. M. King. Jour. Tennessee Med. Ass.,
13: 365-368, 1921.
Biography by H. A. Royster. Surg., Gynec. and Obst., 35 : 2 37
2 39 , x 922.
674. Medical Classics
Biographical sketch by 0 . Clark. Brazil-medico, 36 : 3 °^ I 9 22 -
Biography by H. C. Semple. Amer. Med., Burlington, Vt.,
n.s. 18: 639-646, 1923.
Biography. Virginia Med. Monthly, 50: 494, 1923.
Biography. Med. Jour, and Rec., 122: 687-689, I 9 2 5 *
Biography. Clin. Med., Chicago, 33: 535 ~ 53 6 > 2 9 26 -
Biography by S. Brunson. Jour. South Carolina Med. Ass., 22:
174-175, 1926.
The Sims memorial address on gynecology. By D. Bissell.
Amer. Jour, Surg., 5: 526-534, 1928. Also, abstr.: Jour.
South Carolina Med. Ass., 24: 9-1 1, 1928.
Landmarks in surgical progress: J. Marion Sims and vesico-
vaginal fistula, By I. S. Cutter. Internat. Obst. Surg.,
47: 173-175, 1928.
Biographical sketch in Dictionary of American Medical Biog-
raphy. New York, Appleton, 1928.
Genito-urinary fistula in female, with appreciation of Sims and
his work. By D. Bissell. Proc. Roy. Soc. Med. (Sect.
Obst. and Gynec.), 22: 1-18, 1928. Also: Amer. Jour.
Surg., 7:143-156, 1929.
J. Marion Sims, surgeon and humanitarian. By D. Bissell.
Amer. Jour. Surg., 6: 561-565, 1929.
Biography by S. Leigh. Virginia Med. Monthly, 56: 502-506,
1929.
Sims memorial unveiled May 10, 1929, in Columbia, S. C.
Columbia, 1929. 20 cm., 29 pp.
Eponyms: James Marion Sims. Amer. Jour. Surg., 8, suppl.:
498-499, 1930. Also in: xMidominal cavity and peritoneum.
By E. M. Livingston. New York, Hoeber Co., 1030. pp.
82-83.
Biography by C. K. Weil. South. Med. Jour., 23: 670-671, 1930.
Biographical brevities: Sims’ position. Amer. Jour. Surg., 13:
578 , 1931.
An appreciation. By I. Abell. South. Med. Jour, 26: 1013-
lol 9 > 1933 -
J. Marion Sims, father of gynaecological surgery. By Jennie
MacMaster. The trained Nurse and Hosp. Rev, 92: 121-
I2 7 > 1934 -
James Marion Sims 675
Sims’ statue. New York Times, Feb. 23, 1934. Also: New
York Times, Oct. 21, 1934.
Address at the rededication of the Sims’ memorial, Oct. 20, 1934.
By J. H. Finley. New York, 1934. 2 1., 24 cm.
Sims and origin of modern gynecology. By G. G. Ward. Bull.
New York Acad. Med., 12: 93-104, 1936.
Sims, father of modern gynecology. By S. Harris. South.
Surgeon, 6: 35-52, 1937.
The “Scotch-Irish” of the valley of Virginia, and their influence
on medical progress in America. By H. H. Trout. Ann.
Med. Hist., 10: 71-82, 1938.
INTRODUCTION
Like McDowell, Sims was born in rural America, but not until
1813, forty-two years after McDowell’s birth. He received the
best ’medical education obtainable, graduating from Jefferson
Medical College in 1835. He then began practice in Alabama and
rapidly became known as a capable and original surgeon. Sur-
gery had advanced since the days of McDowell. In 1835 Sims
operated successfully for an abscess of the liver and two years
later he removed both the upper and lower jaw of a patient.
But when Sims began to practice Lister’s earliest work on anti-
sepsis was thirty-two years in the future and anesthesia was un-
known. Sims’ surgery was far from that which we know today.
In 1845 Sims was called to attend a woman who had fallen from
a horse. His examination disclosed a displacement of the uterus.
In making a digital examination by the vaginal route with the
patient on her knees, Sims w-as suddenly unable to feel the dis-
placed uterus and the patient was relieved of her complaint.
As the patient was turned onto her back Sims noticed a sudden
expulsion of air from the vagina. He immediately guessed that
the patient’s knee-chest position aided the replacement of the
uterus.. He determined to use this position as a routine for vag-
inal examination. To aid him he devised a special speculum
which allowed air to enter the vagina so that its walls could be more
readily visualized. Later Sims found that the left lateral posture
was equally as effective for vaginal examination as the knee-
chest position.
Sims then became interested in a very troublesome condition
which had resisted operative treatment; namely, vesico-vaginal
fistula.. Sims was able to repair the fistula successfully because of
four principles; namely, 1. The left lateral posture made visualiza-
tion easier and better; 2. The vaginal speculum exposed the fistula
opening; 3. A special silver wire suture effectively held the re-
paired tissues until healing could take place; and 4. The bladder
was kept empty by a catheter until the fistulous tract had healed,
cams first report On the treatment of vesico-vaginal fistula of 1852 is
reproduced completely in the following pages.
. Sims removed to New York in 1853 where he was instrumental
m establishing the State Hospital for Women two years later.
e visited Europe in 1861 and performed his fistula operation
° p T„ e , moSt °? the s «rgeons of the time. He originated
f!L operations on abdominal organs and was one of the great-
Sat of g Mrn° f h m da m H V S Work forms an exc ellent adjunct to
Sodem Wdr -V Tl ? etl ! er these ™> ■*» P»ved the way for
modern surgery within the abdomen.
On the Treatment of Vesico-
Vaginal Fistula
by
J. MARION SIMS, M.D.
Montgomery , Ala.
[With twenty-two wood-cuts]
Published in The American Journal of , he Medical Sciences, Philadelphia, :85a, New
Series, Vol. XXIII
fESICO-VAGINAL FISTULA— an abnormal
communication between the bladder and
vagina, allowing an involuntary discharge ol
urine — is produced generally by tedious labour,
a The impacted fetal head, jamming the anterior
A vaginal parietes against the symphysis pu is,
obstructs the circulation of the parts, which results « a dough
of greater or less extent, according to the degree and “ 3 ‘
the impaction. Almost the only hope of
disaster under auch cucum«ances „ At m y* confined
mental del, very. By this me^ si otherwise, it would
to the vaginal mucous membrane, , ^ h the vag i n o-
unquestionably have extended 7 i abours where the
vesical septum. It occurs princip J ■ b fatal cranium
pelvis is small, the soft parts unyielding, and the to*
farge; but I have seen it in to
birth previously to many childre • ^ ^ ^ awkward use of
attribute the accident, many & analysis G f these
obstetrical instruments; but, fr
677
678 Medical Classics
cases, and from my own experience, I am well satisfied that for
one case thus produced, their judicious application has prevented
it fifty times.
Other causes produce it occasionally, such as a prolonged re-
tention of a pessary in the vagina, a calculus or other foreign
body in the bladder, abscesses, venereal ulcerations, &c. I have
seen one case where the whole base of the bladder was destroyed
by a corroding ulcer, which, originating in the cervix uteri, ex-
tended forward to the urethra. Whatever may be the cause of
this distressing affection, it is a matter of serious importance to
both surgeon and patient that it be rendered susceptible of cure.
Its diagnosis is sufficiently easy. Incontinence of urine, fol-
lowing a tedious labour after a lapse of from one to fifteen days,
will always prove its existence. But to determine the exact size,
shape, and relative position of the artificial opening requires
some nicety of examination. The consequences of the involun-
tary discharge of urine are indeed painful. The vagina may be-
come inflamed, ulcerated, encrusted with urinary calculi, and
even contracted; while the vulva, nates, and thighs are more or
less excoriated, being often covered with pustules having a great
resemblance to those produced by tartar emetic. These pus-
tules sometimes degenerate into sloughs, causing loss of substance,
and requiring a long time to heal. The clothes and bedding of
the unfortunate patient are constantly saturated with the dis-
charge, thus exhaling a disagreeable effluvium, alike disgusting to
herself and repulsive to others.
The accident, per se, is never fatal; but it may well be imagined
that a lady of keen sensibilities so afflicted, and excluded from
all social enjoyment, would prefer death. A case of this kind
came under my observation a few years (p. 60) since, where the
lady absolutely pined away and died, in consequence of her
extreme mortification on ascertaining that she was hopelessly
incurable.
The relative position of the fistula has served generally as the
basis of a classification. Thus we have:—
ist. The urethro-vaginal, where the fistula is confined to the
Vesico- Vaginal Fistula 679
2d.- Those fistula; situated at the neck of the bladder, or root of
the urethra, destroying the trigonus vesicalis.
3d. Those of the body and bas-fond of the bladder, of which,
Velpeau says, there is no fact, up to the present time, which
proves indisputably that they have ever been cured.”
4th. The utero-vesical, where the opening communicates with
the body or cervix of the uterus.
I have never met with one of the last-named class; but of the
others I have seen a great variety, embracing almost every pos-
sible shape and size.
The position of the patient for the operation, the speculum,
the means of vivifying the edges of the fistulous opening, the
suture apparatus, and the catheter which I shall describe, are, I
believe, original with myself, having been suggested by the
peculiarities of individual cases. The final perfection of these
mechanical contrivances has been the slow work of experiment.
At the first, I had three cases, upon which I operated about
forty times, but failed in every instance to effect a perfect cure,
though succeeding so far as to encourage me to persevere. Now,
I think I may say that almost every case of this hitherto intract-
able affection is rendered perfectly curable.
Before detailing my operation, it may be interesting historically
to take a brief survey of the surgery of this disease up to the pres-
ent time.
For the last half century, though surgeons have laboured as-
siduously to cure it, they have almost always been unsuccessful.
Cases have, now and then, been remedied, but they were so few
that no general principles of treatment could be established, and,
consequently, no certainty of success, in any single instance,
could be predicated.
The suture was, of course, the first surgical appliance that sug-
gested itself to the mind of operators. It was used in a its
various modifications without success. The great difficu ty o
applying the suture, and its signal failure, caused surgeons to
invent a number of instrumental apparatuses, all o w ic are
clumsy and complicated. . . . ,
As a curiosity, let me here introduce a description o t e ap
68 o Medical Classics
paratus of Lallemand, the distinguished professor, of Mont-
pellier: —
“It is composed— xst, of a large canula about four inches long; ad, of a
double hook, which is moved in the principal instrument by means of a
stem, in such manner as to push it out, or to make it enter its sheathed,
of a circular plate which terminates the other extremity of the canula,
and which would hinder, if necessary, this latter from penetrating too
deep into the urethra; and, 4th, of a cork-screw spring, intended to
draw forward the small hooks as soon as they are inserted in the pos-
terior lip of the fistula. The canula, being passed into the bladder,
allows of our pushing the two small hooks into the vagina through the
vesico-vaginal septum, which latter is supported by the left (p. 61) fore-
finger. By making a turn of the screw, they are kept in this position; a
pledget of lint, or fine linen, designed for protecting the tissues, is then
placed between the front part of the urethra and the external plate of
the canula; finally, we relax the spring which acts then, at the same time,
by making traction on the posterior lip with its hooks, and by pressing
backwards the lower wall of the urethra by means of the circular plate,
or the lint, which serves as its point d'appui. By a mechanism which
would be too long for description, we may regulate the stop of the spring
in such manner that there will only result from it a moderate degree of
pressure, though sufficient for bringing the two borders of the fistula
in contact.”— Velpeau, vol. iii. p. 85a.)
The apparatuses of Lewziski, of Dupuytren, of Laugier, of
Fabbri, and others, are equally complicated, quite as unfit to
fulfill the proper indications of treatment, and, by experience,
have proved as wholly worthless.
_ Others have attempted to improve different stages of the opera-
tion. Thus Colombat praises his spiroidal needle for passing a
whip suture in longitudinal fistulas, and M. Sanson has proposed
to enlarge the urethra by a double lithotome for the purpose of
carrying the finger through the urethra into the bladder, merely
to depress the fistula toward the vulval opening; while Wutzer
proposes, and performs in a great number of cases, the high
operation of paracentesis vesicse, confining his patient for several
a ^ S u ° n er a bdomen, by means of cushions, straps, and buckles.
i hese are referred to as historical facts
that could possibly result from them.
, and not for any good
Vesico- Vaginal Fistula 68 1
While all these formidable contrivances, and the suture, have
failed so signally, cauto izcition has but little more to boast of in
the way of success. Very small fistulous openings have occasion-
ally been reported as cured by the application of the nitrate of
silver, a catheter being retained in the bladder; but, in fistulas
of any size, it has proved entirely abortive.
To show how utterly hopeless have been all our efforts hereto-
fore, we may allude to the suggestion of some of the French sur-
geons to apply the Taliacotian method of anaplasty to this
operation, which has actually been repeatedly performed by
Roux, Jobert, and others; and, also, to the operation of M.
Vidal, for an “obturation of the vulva,” whereby the bladder and
vagina become a grant compound receptable of the urine and
menstrual secretion. It is an idle waste of time to dwell longer
on means so perfectly ineffectual, not to say mischievous.
But have no useful, practical suggestions been made, as yet,
by any one on the treatment of vesico-vaginal fistula? Yes:
two names stand out in bold relief amongst those who have de-
voted some time and attention to this subject. I allude to our
own countryman, Mettauer, who uses leaden sutures; and to
the indefatigable Jobert, who is the author of the operation of
autoplastie par glissement. The first, by his plan, has cured
several cases; while the latter has achieved a greater degree of
success than any other surgeon.
Thus, all that we know on the subject worth knowing is due to
America and France; while German and British surgery have
done comparatively nothing for the amelioration of this loath-
some and troublesome disease.
(p. 62) Many of our systematic works pass it over in silence, or
dismiss it with a few remarks discouraging all attempts at treat-
ment. Samuel Cooper, in his great Surgical Dictionary, does not
introduce the subject even by name; while Liston devotes ess
than a page to it. Alluding to the application of the heated wire,
he says: “By this means a small opening may occasiona y e
made to heal up. But when the communication is to a large
extent, but little hope remains to the patient. ergusson,
Gibson, and others say nothing about it; while 1 ar ismisses
582 Medical Classics
it as summarily as did Liston. But how could it be otherwise,
when its mechanical treatment is so imperfect that no general
principles could be laid down?
It is not my intention to allude to all that has been attempted
by different surgeons; but it is equally a duty and a pleasure here
to chronicle what has been done by our own countrymen who lay
any claims to originality or credit.
The first successful case in this country is, I believe, by Dr.
Hayward, of Boston. The following is his description of the
operation: —
“The patient was placed on the edge of a table, in the same position as
in the operation for lithotomy. The parts being well dilated, I intro-
duced a large bougie into the urethra, and carried it back as far as the
fistula. In this way I was able to bring the fistula downwards, so that
the opening was brought fairly into view. The bougie being then taken
by an assistant, I made a rapid incision with a scalpel around the fistula,
about a line from its edges, and then removed the whole circumference of
the orifice. As soon as the bleeding, which was slight, had ceased, I
dissected up the membrane of the vagina from the bladder, all around
the opening, to the extent of about three lines. This was done partly
with the view of increasing the chance of union, by presenting a larger
surface, and partly to prevent the necessity of carrying the needles
through the bladder. I then introduced a needle, about the third of an
inch from the edge of the wound, through the membrane of the vagina,
and the cellular membrane beneath, and brought it out at the opposite
side, at about an equal distance. Before the needle was drawn through,
a second and a third were introduced in the same way; and these being
found sufficient to close the orifice, they were carried through, and the
threads^ tightly tied. Each thread w’as left about three inches in
length.” {Am. Jottm. Med. Sciences, Aug. 1839.)
Besides this case, Dr. Hayward has recently reported eight
others, operated upon since August, 1840, two of which were
entirely successful. He says:
The operation was done in every instance by ligature. The result
as, on e w o e,. been satisfactory. Any thing that is calculated to
e j- 1S - , n or t0 lessen in the slightest degree the sufferings
of the individuals who are afflicted with it, should be made known.
Vesico-Vaginal Fistula 683
**I had never seen the operation done until I did it myself, nor could I
find any description of the mode which others had adopted, that was
sufficiently clear and explicit to be of much service. I had, therefore
to take such a course as I thought save, and at the same time likely to
effect the object, viz: the closeure of the fissure. I do not know that
others may not have operated precisely in the same way; but if they
have, I am not aware of it.
“J performed the operation twenty times, but it was done on nine
patients only, one being operated on six times, another five, two twice,
and five once/ ( Boston Med . and Snrg , , 'Journal , vol. xliv., No. Ii.
April 16, 1851.)
Dr. Pancoast, of Philadelphia, has operated successfully in two
cases, by the following method: —
{
“The peculiarity of the operation consists, virtually, in attaching the
two sides of the anormal opening firmly together, on the principle of the
tongue and (p. 63) groove, so as to get four raw surfaces in contact, and
thus increase the probabilities of union by the first intention. For this
purpose it is necessary that the margins of the fistula should have con-
siderable thickness, and when not found in this state, they are to be
thickened by repeated applications of lunar caustic; or, better still, of
the actual cautery.
Having exposed the fistulous orifice as thoroughly as possible with a
Charriere’s speculum, from which the sliding blade has been removed,
an assistant at the same time drawing the vestibulum well up towards
the front of the pubis, my first object in the operation is to split the
most posterior margin of the fistula to the depth of half an inch. I
next pare off the edges of the other lip of the fistula, so as to bring it into
a wedge shape; first reverting it as much as possible with a small blunt
hook, and trimming off the mucous membrane on the side next the
bladder with the curved scissors or scalpel, and then detaching, in like
manner, the vaginal mucous membrane, to the breadth of three-quarters
of an inch, along the whole extent of the lip- This was a very difficult
but most important part of the process. Having checked the bleeding
by the use of astringent applications, my next object is to insert the raw
wedge or tongue, into which one of the lips of the fistula has een con-
verted, into the groove which has been cut in the other, and o t em
in close connection. This I accomplish by the means of a peculiar
suture that might be called the plastic, and in the same way t at ave
6B4 Medical Classics
described its application in reference to some plastic operations in my
Operative Surgery; and in the American Journal oj the Medical Sciences
for October, 1842.
“When the sutures are knotted firmly, the tongue or wedge will be
found immovably imbedded in the groove. The sutures I leave for two
weeks or more, or until they become loose. A gum catheter should be
kept in the bladder to prevent the accumulation of urine. To keep the
inflammation from running to a destructive height, a bladder of cold
water should be applied for thirty-six hours to the vulva.
“On the second or third day, I direct the frequent injection of a solu-
tion of zinci sulph. into the vagina, in order to increase the tone of the
parts. On the fourth or fifth day, I apply to the line of union a solution
of lunar caustic with a camel’s hair pencil. This application should be
made twice in the twenty-four hours, the solution being gradually in-
creased in strength. Union by first intention may be expected to take
place under this treatment to a considerable extent; at such points as it
should fail to occur, union by second intention is to be promoted by the
use of lunar caustic in substance, so as to raise a bed of granulations on
the raw surfaces of the lips, while they are held in contact by the plastic
suture.
“In one case, there was a complete destruction of a cross section of
the whole urethral structure, near the neck of the bladder; in the other,
there was an elongated orifice in the bas-fond of the bladder, which
would more than admit the end of the finger.”— (Med. Examiner, May,
1847.)
Dr. Mettauer’s operation, the peculiarity of which consists in
the use of leaden sutures, is described in the Am. Joum. Med.
Sciences for July, 1847, to which I beg leave to refer the reader
for particulars.
Having thus briefly alluded to what has been done, up to the
present time, for the treatment of this affection, I shall now pro-
ceed to detail my own operation.
I conceive that I may claim originality: 1st. For the discov-
ery of a method by which the vagina can be thoroughly explored,
and the operation easily performed.
ad. For the introduction of a new suture apparatus, which
lesim e e in the tissues for an indefinite period without danger
of cutting its way out, as do silk ligatures.
Vesico- Vaginal Fistula 685
And 3d. For the invention of a self-retaining catheter, which
can be worn (p. 64) with greatest comfort by the patient during
the whole process of treatment. °
Of the position 0/ the patient for the operation .— With the excep-
tion of Velpeau and Chclius, all other operators, even Jobert,
recommended that the patient be placed on the back as in the
operation for stone.
Velpeau* says, “A round-shaped mattress is placed under the belly,
in such manner as to enable her to keep her thighs flexed, while lying
upon her abdomen. An assistant keeps the vagina dilated by means of a
large gutter of metal, horn, or thin wood.”
Chcliusf directs "the patient to be placed on her belly upon a table
covered with a mattress, so that she may kneel near its edge, with her
head and chest bent forwards, and supported with small bolsters. The
operator sits between the patient’s thighs, upon a scat of proper height,
so that his arms should not soon tire.”
In 1845, previously to the translation of cither Velpeau of
Chclius, I hit upon the proper plan of exploring the vagina in these
cases; but to the latter is due to the first published account of even
a hint towards that method.
In order to obtain a correct view of the vaginal canal, I place
the patient upon a table about 2-1 by 4 feet, on her knees, with
the nates elevated, and the head and shoulders depressed. The
knees must be separated some 6 or 8 inches, the thighs at about
right-angles with the table, and the clothing all thoroughly
loosened, so that there shall be no compression of the abdominal
parictcs. An assistant on each side lays a hand in the fold be-
tween the glutei muscles and the thigh, the ends of the fingers
extending quite to the labia majora; then, by simultaneously
pulling the nates upwards and outwards, the os externum opens,
the pelvic and abdominal viscera all gravitate towards the epi-
gastric region, the atmosphere enters the vagina, and there,
pressing with a weight of 14 lbs. upon the square inch, soon
stretches this canal out to its utmost limits, affording an easy
* Operative Surgery, Am. edition, vol. Sii. page 8ji.
f Chclius* Surgery, by South, Am. edition, vol. ii, page 191.
686 Medical Classics
/
view of the os tincse, fistula, &c. To facilitate the exhibition of
the parts, the assistant on the right side of the patient introduces
into the vagina the lever speculum represented in Fig. I, and
then, by lifting the perineum, stretching the sphincter, and rais-
ing up the recto-vaginal septum, it is as easy to view the whole
vaginal canal as it is to examine the fauces by turning a mouth
widely open, up to a strong light. (See Fig. 4.) This method
of exhibiting the parts is not only useful in these cases, but in all
affections of the os and cervix uteri requiring ocular inspection.
The most painful organic diseases, such as corroding ulcer, car-
cinoma, &c., may be thus exposed without inflicting the least
pain, while any local treatment may be instituted without danger
of injuring the healthy structures. By this method, also a
proper estimate, anatomically, can be had of the shape and ca-
pacity of the vagina; for where there is no organic change, no
contraction, and no rigidity of it from sloughs, ulcers, and cica-
trices, and where the uterus is movable, this canal immediately
swells out to an enormous extent, thus showing its great ex-
pansibility.
(p. 65) Fig. 1 represents the speculum. When introduced and
held properly, it causes no pain whatever. It is well enough to
have two or three of different sizes, so as to be prepared for any
case. The one ordinarily used by me is about a?, inches from a,
where it supports the sphincter, to its terminal extremity at b.
Its concavity c, c serves to reflect a strong light down on the
vagino-vesical septum, the seat of fistula. Its breadth from d
to e is about £ths of an inch, widening a little as it approaches
the end, making it somewhat in the shape of a duck’s bill. The
handle is made strong and unyielding, because a considerable
degree of leverage has to be exercised by it. The curve at /,
being cushioned to prevent its hurting the forefinger, fits accu-
rate } over it. The whole instrument is made of German silver,
the concavity being highly polished for reflecting the light.
A small, slightly convex spatula, Fig. a (of German silver),
ay occasiona y be needed to press the urethra downwards
gainst the symphysis pubis, when there is a very minute fistula
Ae nei g h bourhood of the trigonus vesicalis; (p. 66) particu-
Vesico-Vaginal Fistula 687
larly if the urethra! folds arc very redundant. This will seldom
be used, but is sometimes indispensable, not only in exploration,
but in holding the healthy parts out of the way in passing sutures!
These simple instruments, with this position and a good light,
are all that arc necessary for obtaining an accurate view of the
parts. If the vagina and outlet are ordinarily capacious, a good
Fig. 2.
strong northern light, of a clear day, from a large solitary window,
is all-sufficient. But if this canal has been narrowed by cicatrices
after extensive sloughs, or from other causes, then sunlight is
absolutely necessary for every stage of the operation from rst
to last. For this purpose, a small table is placed near a win ow
admitting the sun-light. An assistant, sitting by, adjusts on t e
588 Medical Classics
table a glass, Fig. 3, some eight or ten inches in diameter, so as to
throw the rays of light into the vagina, which, passing to the right
of the operator, and striking the concave surface of the bright
speculum, are reflected down on the anterior vaginal paries,
making everything perfectly distinct.
Fig. 4 shows the speculum introduced, elevating and support-
ing the sphincter; also the relative position of the organs, when
the patient is examined as directed; the vaginal canal being dis-
tended to its greatest capacity.
Fig. 3. Fis * ( -
Of scarifying the edges of the fistulous opening . — This was the
most tedious and difficult part of the operation with me, as it
has always been with others. For three or four years, I had great
trouble in getting such instruments (p. 67) made as I thought
indicated; but those I now use for this purpose are so simple,
that they can be had anywhere. A delicate tenaculum, Fig. 5,
and a sharp-pointed knife, Fig. 5, b, are alone necessary.
• P e te ” acu lum> Fig. 5, n, is very small; the curve being at
nght angles with the shaft, and not more than one-third of an
Vesico-Vaginal Fistula 689
Fi C . 5-
inch long. If longer, it is not easily managed, nor so generally
applicable to any and every part of the fistula. e ®
some five or six inches long, it set into a firm han e.
690 Medical Classics
size and shape, it can be used to elevate the edge of the opening
with equal facility, whether laterally or otherwise; while, if
curved at more than a right angle, it can be useful only in hook-
ing up and drawing forward the anterior and posterior margins.
Fig. (j represents the tenaculum hooking up and elevating the
edge of a fistula, while the point of the knife b is applied, ready to
separate the part so raised up. This process is continued till the
edge of the opening is well vivified all round (as seen by the dotted
line), sometimes removing a strip an inch or more long before it
is cut or torn off. The denudation is to be from a quarter to the
third of an inch wide. I have often made the mistake of not
removing enough of the callous edge; but I now take good care to
remove it freely, extending the scarification up on the vaginal
surface. I do not remove any of the lining membrane of the
bladder, unless it is very much altered in character, and projects
through the fistula into the vagina in such a way as to obstruct
the easy performance (p. 68) of the operation; which rarely hap-
pens, and only where there is a great loss of substance.
Where the fistula is very small, say not larger than a common-
sized probe, or even as small as a number seven or eight sewing
needle, the best plan to scarify is, to hook up the part with the
tenaculum, pull it forward, and by a thrust of the knife transfix
the entire thickness of the vagino-vesical septum; then by a
circular sweep of the instrument, the whole fistulous track may
be removed at once; which substitutes for the small and callous
opening, a smoothly cut orifice of rather a conical shape, large
enough to admit the end of the forefinger.
. ^ ^ ere the fistula is so small, there is always an abundance of
tissue, and there need be no fear of removing the parts freely; for
it is easier to dose properly an opening as large as the end of the
nger, than a smaller one, provided there is no scarcity of tex-
ture.
Where the fistula, on the other hand, is very large, there is
occasions y some trouble in determining exactly what to cut;
ecause y t e bearing down, sobbing, straining, or even volun-
v>wm reS1StanC i e °/ t ^ e P atlent J t ^ ie mucous membrane of the
er ma) e forced out in voluminous folds, so as to render
Vesico-Vaginal Fistula 691
the fistulous edges indistinct, and there is danger of scarifying,
either too high up on the vaginal surface, or too far in on the
vesical lining. To obviate this difficulty, a properly curved
metallic bougie may be passed through the urethra up to the
fundus of the bladder; thus putting the parts on the stretch and
carrying back into its cavity, the apparently redundant lining.
The bougie curved down between the thighs may be held by a
third assistant. But I greatly prefer to introduce a bit of soft
sponge, of proper size, into the cavity of the bladder, which
forces back the lining membrane, leaving the fistulous boundary
distinct, when the scarification may be easily accomplished.
The introduction of the sponge into the cavity of the bladder, or
merely between the edges of the fistula, as well as its removal, is
always attended with very great pain. Once introduced, I allow
it to remain, till the sutures arc passed and ready to be secured.
During the scarification, there is, of course, always hemorrhage;
and, in some instances, it is so profuse as to compel us to desist
for a short time, the patient being allowed to change her position
and rest. As soon as the bleeding ceases, the operation may be
resumed.
To remove the blood from the cut surface during the scarifica-
tion, a probang is necessary (Fig. 6), which is made by tying a
nice bit of sponge to the end of a piece of whalebone some eight
or ten inches long. It is well enough to have two or three of
these, which will keep one assistant pretty busy to wash clear of
blood at this stage of the process. The probang can generally
(p.69) be best applied by the operator, as his position allows him
to see exactly where it is most needed.
I cannot lay too much stress on the great necessity of perfecting
well this part of the operation; for, upon a proper and free denuda-
tion of the fistulous orifice, success or failure will mainly depend.
Sometimes one edge of the fistula is thinner than another.
Velpeau and others have noticed this fact, but in not a single
instance have I found (as they did) the thinner edge behind and
the thicker before. Where there was any appreciable difference,
the reverse was the fact in every case that I have as yet examine .
This thinning of the anterior edge, where it was right at the nec c
Medical Classics
69 2 . nh stacle to the proper closure
of the bladder, teas *£%£•**$
on r Fig- 6.
Of the Suture Apparatus.— Sutures all sen ^the ^ we
purpose, viz. the bringing and holding S ? c } rCU m-
lish to unite. They are variously named ,«»«*«* continued,
stances-as the Interrupted, because it is sol tar) th be _
because a plurality of them are joined together, the yu
Vesico-Vaginal Fistula
cause of the peculiar method of securing it; and the Twisted,
for a similar reason.
The one that I use for closing vesico-vaginal fistulae, I have
termed the clamp suture, from its peculiar method of action.
Thus, if the profession allow me to introduce a new suture by its
most appropriate name, we shall then have in general use, sutures
named, first, according to their relation, the interrupted and
continued. Second, according to the method of securing them,
the quilled and twisted; and third, according to its method of
action, the clamp suture.
As all sutures are but modifications, one of another, so is the
clamp a modification of the quilled.
The clamp suture is composed of small annealed silver wire
fastened to cross-bars, after the manner of the quilled suture.
The wire is drawn down to about the size of a horse-hair, and then
annealed. The cross-bars, or clamps, are very small, not more
than a line in diameter, and made of silver or lead, as most con-
venient. If of silver, they may be tubular; when of lead, solid.
They must be highly polished, and without the slightest asperity,
particularly at their extremities. They act as clamps in this way.
The parts embraced between them, being held in close apposition,
swell upward, and overlap them; while they, by pressure, produce
an ulceration in the vaginal surface, sufficient to allow of their
being perfectly embedded, and after a while even sometimes hid-
den from view. This ulcerative process is attended, of course,
with a purulent discharge, which, continuing for three or four
days, diminishes, and soon ceases altogether; but not till the bed
made by the clamp becomes (p. 7°) l> ne d with mucuous mem-
brane. After this the apparatus would lie innocuously in the
tissue for an indefinite period. I have allowed it to remain
long enough for the extremities of the clamps to be covered over
completely by firm granulations, which, opposing considerable
resistance to their removal, had to be lacerated before this could
be accomplished.
This suture is far preferable to anything before suggested or
the purpose. Its introduction dates from June 1849, since whic
time I have had comparatively little trouble in the treatment of
6 Medical Classics
the great majority of cases of vesico-vaginal fistula. Properly
applied, this suture never ulcerates out, having always to be re-
moved by means of scissors, hooks, and forceps. It may be
allowed to remain intact for six, eight, or ten days, or even longer.
If removed too soon, the delicate cicatrix may gradually yield
to the traction of the ascending uterus, or to the force exerted
by the bladder in expelling its contents, and thus reproduce a
small fistulous orifice to be closed by a subsequent and more
cautious operation. I have seen the new cicatrix give way from
another cause, and perhaps it is the chief one. The clamps,
burrowing in the vaginal surface, leave a deep sulcus or fissure on
each side of the new cicatrix, which, when they are removed too
soon, fill up by granulation. It is a law of all granulating wounds
to contract as they heal, and this contraction on each side of the
new cicatrix is often sufficient to pull it gradually apart. But if
the clamps are allowed to remain till their sulci are covered with
mucous membrane, then there is no danger of this accident, for
these chasms then gradually disappear, less by filling up with
granulations, than by an absorption of their elevated edges.
Accidents of this sort have happened repeatedly in my hands,
from a too early removal of the suture apparatus. Great judg-
ment, which experience alone can give, is necessary to determine
the length of time that the sutures ought to remain intact, for
no positive rules can be laid down that will answer invariably in
every case.
I have also seen serious mischief result from leaving the clamps
too long embedded in the parts. Their burrowing and ulcera-
tion may extend entirely through the vagino-vesical structure,
thereby substituting new fistulous openings for the original one.
This complication is by no means incurable, but only prolongs
the treatment, and postpones ultimate success.
In two or three instances I have witnessed a still more serious
acci ent rom an undue pressure of the clamps, viz. a strangula-
tion o t e enclosed fistulous edges, which unfortunately resulted
n a s oug ing of the tumefied parts, and consequent enlarging of
e opening. In no instance, however, has this accident rendered
e case ope ess, or even caused me to feel any concern either
Vesico-Vaginal Fistula
695
for the immediate safety of the patient, or for ultimate success
in treatment.
After the scarification is completed, the patient is allowed to
rest for a few (p. 71) minutes, before the introduction of the su-
tures; an operation which is somewhat tedious, but not difficult.
The number of sutures will depend on the size of the fistula.
Less than two will not suffice for the smallest opening, w ie
the great majority of cases will require three; and, occasiona y,
we meet with one sufficiently large to demand four.
The needle which I use is represented by Fig. 7. It is 3W _
6g6 Medical Classics
shaped, and spear-pointed, with the eye near the point. The
shaft is about six inches long; the part near the handle is made
malleable, allowing it to be bent into any desirable shape for the
purpose of preventing the hand, as it grasps the handle, from
obstructing the view of the operator.
To illustrate the method of suture, let us suppose a case, where
the fistula is oval, transverse, occupying the bas-jondo f the blad-
der, about half way between the urethra and os tinae, in the
mesial line, and large enough to admit the end of the index finger.
This, in shape, size, and position, is altogether the most favourable
case that can occur, both for a near performance of the operation.
Pig. 8.
r*
and for certainty of success. Such a fistula will require three
sutures.
Fig. 8 represents them introduced at proper intervals; the two
outside ones passing within a fourth of an inch of the angles of the
fistula. The middle one is first applied. The needle, armed with
a silk thread, is entered about half an inch anterior to the scarified
edge of the fistula; pushed deeply into the vesical septum, with-
out transfixing it; brought out just at the edge of the mucous
lining of the bladder; carried across the opening; made to enter
the opposite side at a point corresponding with its direction an-
teriorly, observing the same precautions in its course; while it is
brought out on the vaginal surface about half an inch beyond
the scarified part.
Vesico- Vaginal Fistula 697
The passage of the needle through the anterior edge of the open-
ing is easy enough; but the loose and yielding nature of the pos-
terior, renders some support necessary before it can be made to
appear on the vaginal surface. For this purpose a blunt hook
(Fig. 9, a) is placed flatwise, just beyond the spot at which we
intend the needle to come out, thus making a fixed point for it,
when it passes with great ease.
(p. 72) Fig. 9, b, shows the needle armed and passed as directed:
the spear-point having emerged at its proper place on t e ista
6g8 Medical Classics
side of the fistula, is supported by the blunt hook, a, over which
it rests.
As soon as this is accomplished, the blunt hook is laid aside,
and a small tenaculum (Fig. io, a) used to hook up the ligature
which lies close by the side of the needle, b. There is sometimes a
little delay in doing this, particularly if the parts are too con-
tracted, or the light not good. In this case, the needle should
be pushed an eighth or a fourth of an inch further on, and then
retracted as much, when a little loop of ligature will be left, into
which the tenaculum can be passed. (Fig. io.) After this, the
needle is to be withdrawn entirely, leaving the ligature in situ,
with its distal end or loop securely on the hook. The hook is
then drawn out, and with it, of course, the ligature, (p. 73) the
two ends of which are now hanging from the vulva. The other
ligatures are passed in like manner, observing the precautions
already laid down.*
In pulling on the distal end of the ligature, another expedient is
necessary to prevent the cutting and pain, which would inevit-
ably attend its passage over the posterior edge of the fistula.
For this, a crescent-shaped fork (Fig. 11) mounted on a shaft
of convenient length, is passed up, which, pushing the ligature
above its furthest point of exit, serves the purpose of a pulley;
when it (the ligature) can be easily drawn backward or forward
by traction on either end, without inflicting the slightest injury
on the part, or pain on the patient.
Having now given directions for passing the ligatures, let us
suppose that we have introduced the three, or as many as we
want. The difficult part of the operation is over, and we have
The hgatures cannot always be introduced with as little trouble as in the case jus^
supposed. For instance, when the loss of substance is very great, the fistula is so wide
that the needle cannot be made to traverse both sides of it at once; hence, it becomes
necessary to hook up the ligature as soon as the needle has pierced the anterior border
of the opening; when it is withdrawn, re-threaded with the distal end of the same liga-
ture, and passed through the posterior edge. In re-threading the needle, care must be
taken to pass the thread through the eye from its upper or concave surface; otherwise,
when it is withdrawn, it will be found still hanging to the main thread that is stretched
across the fistula, instead of slipping easily from its free end: which is a very awkward
accident, inasmuch as the patient is subjected unnecessarily to the pain and delav of
having it introduced again.
Vesi co- Vaginal Fistula 699
only to substitute the annealed silver wires for the silk ligatures;
which is the work of but a few minutes. Take a piece of the wire*
twelve or eighteen inches long, making a small crook at one end so
as to fasten it securely to one of the ligatures. Fig. 12 shows the
Fig. 11.
wire crooked and hanging to the end of the thread; the ot er en
of the thread being pulled on till it comes out, leaving the wire in
its place. In the same way we replace the remaining silk lga-
tures with silver wire; both (p. 74) en( ^ s which project rom
700
Medical Classics
the vulva, the proximal directed downward, and the distal held
upward.
The next step is to secure them by means of the clamps. In
Fig. 13 the wires were represented passed, the two ends of each
Fig. 13.
Fig. 14 .
rl°i the ™‘ Va vl he distal «• «, to the left; the proxi-
ss: b ; r ^ to suit ' he d r
“ to the ba/or elamp ^^e £
7oi
Vesi co -Vaginal Fistula
or by being passed through a perforated shot and bent over it.
This done, we now pull upon the proximal ends b b b, and, as a
matter of course, the bar c is carried into the vagina, up above the
fistula, and made to occupy a bed right over the orifices d d d.
Here, the crescent-shaped fork is supplanted by a modification
of it, Fig. 1 4, broad enough to serve the purpose of a pulley for all
three of the wires. The next step is to pass another bar or clamp
on the (p. 75) proximal ends of the wires, and to push it along
them into the vagina, till it occupies a position in front of the
fistula, corresponding exactly with the one behind it.
Fig. 15 shows the two clamps, one on each side of the fistula,
and everything ready for closing it. The proximal clamp is
pushed up by the crescent-shaped fork, while the wires are held
firmly. This brings the denuded edges of the fistula into such
close contact that it would be difficult to enter a common sized
probe between them. The force necessary for tightening the
clamps will depend upon the judgment of the operator, not
enough will allow the parts to gape, while too much, which is the
most frequent fault, will produce the bad effects formerly a u e
to.
A simple and perfect contrivance now serves to hold the c amps
in their proper places. A small bird shot, perforated, is passe
yo2 Medical Classics
along each wire close against the proximal clamp; when, the wires
being held securely, they are gently but firmly compressed by
means of a long strong pair of forceps (Fig. 16), whereby they are
made to perform the office of a knot in preventing the clamp from
slipping off the wire. The wires are cut off about a fourth or
eighth of an inch from the shot, and then bent over, which
effectually prevents their slipping off.
Fig. 17 shows the appearance of the fistula and suture apparatus
after the (p. 76) operation; the edges of the opening in apposi-
Fig. 17.
tion; a clamp on each side of it; the flattened shot against the
proximal clamp; the wires cut off and bent over the shot, which
protects the recto-vaginal surface against their sharp ends, as
well as prevents their slipping.
The operation, which may have lasted some twenty or thirty
minutes, or, under any circumstances, not more than an hour, is
now over, and our patient is ready for bed, complaining only of
xatigue from the constrained position. °
There is one peculiarity about the instruments, which greatly
facilitates the operation. For instance, the tenaculum, the
Vesico- Vaginal Fistula 703
needle, the blunt hook, and the crescent-shaped fork, have their
shafts made malleable, so that they may be bent in a direction to
keep the hand of the operator below the axis of the vaginal
canal, which preserves the line of vision unobstructed.
Of the Catheter. — Surgeons have always felt that something
more was necessary to cure a case of vesico-vaginal fistula, than
merely closing it mechanically. The urine has been the great
cause of failure. To prevent its percolation through the closed
opening has been regarded, heretofore, as almost insuperable.
The catheter was tried by all, but its frequent introduction had a
direct tendency to disturb the healing process, and to hasten the
mischief it was intended to obviate; while all attempts to secure
it permanently in the bladder by any external contrivance has
proved abortive.
Desault used a large gum-elastic catheter, “fixed to an appara-
tus resembling a truss, by means of a movable silver plate, pro-
vided with an aperture for its removal.” Tying it to the hairs of
the vulva, and other equally useless expedients have been re-
sorted to.
According to Chelius, the operation of paracentesis vesicle
was practiced by Wutzer, who, he says, had the greatest success
in the treatment of this disease, having cured three cases out of
eighteen. He compliments the efforts of his countryman by
saying, “That he has importantly contributed to perfecting the
operation, and, by the addition of paracentesis vesica, in order
more completely to draw off the urine, has advanced consider-
ably farther than his predecessors.”
Wutzer gives specific directions for puncturing the bladder
above the pubes: after which a tube is to be introduced, and
“fixed immovably by means of wing screws in the cleft of a
previously well fitted belly girdle, after which, the patient should
be carefully conveyed to a bed previously prepared, placed on
her belly , upon suitably cut out leather cushions , and ptopeily
buckled in it with suitable leather straps .” I allude to this method
by Wutzer, merely to show what desperate efforts have been made
to prevent the urine from escaping through the fistula during t e
process of treatment.
Medical C^lassics
With me, as with others, this has been the most serious ob-
stacle to the success of the operation; for, if a single drop of urine
finds its way through the (p. 7 ?) fistulous orifice, it is sure to be
followed by more, and thus a failure to some extent is almost
inevitable.
Knowing that something to draw off the urine continually was
absolutely indispensable to success, and seeing that all other
operators had failed to secure a catheter in the bladder by any
justifiable external means, I conceived the idea of contriving for
this purpose, a self-retaining instrument. A sponge tent was the
first thing suggested to my mind. I supposed, if a long narrow
piece of sponge could be safely introduced into the bladder, that
it would absorb the urine as fast as secreted, which, by capillary
attraction, would pass along the sponge, and escape without com-
ing in contact with the fistula. Accordingly, a piece of fine
sponge some three or four inches long, narrow in the middle,
larger at each end, with a strong silk thread passing through its
whole length to prevent its being torn, or broken, was first used.
(Fig. 1 8.) Concealed in a bi-valve catheter, it was readily in-
troduced, the middle portion c, enveloped in gold beater’s skin
lying in the urethra, the small flat end a , occupying the cavity of
the bladder, while the larger extremity hung out between the
labia. It acted the part of a syphon admirably, every drop of
urine passing through it; but unfortunately for my patients (two
of whom were experimented on with it), it became encrusted and
perfectly saturated with calculous deposits, rendering its removal
painful, difficult, and even dangerous. This expedient, promis-
ing so much in theory, and performing so ill in practice, was
necessarily abandoned.
Following up the idea of a self-retaining apparatus, I next hit
upon the following contrivance. I took a piece of gum-elastic
bougie (No. 5 or 6 ), some four or five inches long, and made a
longitudinal split an inch long entirely through it, beginning
about a fourth of an inch below the rounded ^end. (Fig. 19.)
A piece of silver wire, a little longer than the catheter, was passed
aong it and fastened neatly at its vesical or split extremity.
Traction on the lower end of the wire caused the sides of the split
Vesico-Vaginal Fistula 705
to open (Fig. 20), which allowed the urine to pass off freely, while
the bulbing at a a held it securely in the bladder. This seemed,
at first, to promise success, but after trying it in various cases for
about twelve months, it, like its predecessor the sponge, had to
be laid aside. There were several (p. 78) reasons for its failure.
If made of a larger catheter than a No. 5 or 6, it would not open
and close with regularity, and hence, would press unequally and
injuriously on the fistula; whereas, when made of a No. 5 or 6,
Fig. is. Fig. 10.
its calibre was not large enough to permit a free disc arge o
mucopurulent secretion which always attends the use o si r en
sutures; and this compelled its removal,, at least two or t ree
times a day, for the purpose of cleaning it out. ence, its re
quent introduction, with the consequent distur ance o
parts from the opening and shutting of the split en , e **
with the healing process to such an extent as to ma e 1
sary to give up its use, entirely. , f •
Foiled in this, I devised another instrument on e •.
ing principle. It was a large silver catheter, curve in p
706
Medical Classics
Fig. ZO.
Fig. 21.
directions, giving it a sigmoid form (Fis? *t) TK a
earned ud behinH l • ^ g ‘ 2I '* lhe end a was
urethra, while the s y m P h y sis P^bis, the part c lay in the
5 hUe th£ extremit y b ^ un S down between the nates.
Vesico-Vaginal Fistula 707
This was the first successful approximation to what was really
wanted. When the patient lay on the back, the end b was
lower than the base of the bladder, which made it literally a
syphon; when she turned on either side, it had a semi-rotation
that still kept the end a upward, while the outer extremity hung
downward over the thigh, inviting the easy passage of the urine.
To insure a free discharge of the muco-purulent secretion along
with the urine, I made a long narrow slit on each side instead of
the holes, as here represented. To see how the instrument would
answer, I introduced it into the bladder of a patient having a very
large fistula. Feeling well satisfied with its performance, I
attempted to remove it and found (p. 7 9) it impossible to do so.
Folds of mucous membrane had projected into the fenestra, and
thus locked it up in the bladder: they were disengaged by the
finger passed up through the fistula. The two long openings
were then closed and several round ones made, about the size of
those represented. They were larger than in ordinary catheters,
on account of the abundant tenacious secretion before alluded to.
I operated on a case, and applied what I then supposed to be
a faultless instrument. Everything progressed well for five or
six days, the catheter remaining in the bladder intact for that
length of time; but now it became necessary to remove it for the
purpose of cleaning out the mucus and urinary concretions that
were obstructing the free egress of the water. But here I was
foiled. I could pull it down for, perhaps, an inch, when it sud-
denly stopped; then by letting it go, it would slip back into the
bladder with a sort of jerk. It evidently seemed to be fastened
there by some means that I could not exactly comprehend.
Every reasonable effort to remove it proving abortive, I, at last,
pulled it out by main force. On its removal, the secret of its
retention was explained by the shreds of mucous membrane
(some an inch long) hanging from each orifice on the under and
lateral surfaces of the catheter. The long-continued presence of
an instrument in the urethra, which was entirely too large for it,
irritated and inflamed the lining membrane, and caused it to
throw out granulations. These, with the granulations o t e
fistula, shot little granules through the holes in the catheter,
7 o 8 Medical Classics
which spread out into button-shaped knobs on its inner surface;
thereby preventing its removal. The injury done to the part,
and the pain inflicted on the patient, may very well be imagined.
This instrument was variously modified (always keeping in
view the self-retaining principle); but it was not reduced to its
present simple form until about three years after this. I will
not detain the reader longer with a statement of the troubles and.
disappointments that were encountered before I got it perfected,
particularly as it will be necessary, in giving the history of in-
dividual cases, to speak of these amongst the causes of failure in
some of the operations.
The urethra in some women is less than an inch long, while in
others it may be an inch and a half; besides, it may be so small in
some, that a No. 5 catheter is as large as can be borne with any
Fig. 2!.
degree of comfort, while others will take a No. 9 or 10, and retain
it easier than one smaller. Thus, it is evident, that almost every
case may require its own catheter, peculiar in length, diameter,
and curvature.
Fig. 11 is a correct representation of the self-retaining catheter,
and exactly of the size and shape that is most generally required.
It may sometimes be curved a little more. The end c is intro-
duced and lodged up behind the symphysis pubis; the part from
aXob lies in tne urethra; while the outer extremity d . , hangs down
immediately below the meatus urinarius; this downward projec-
tion at d serves the double purpose of preventing it from slipping
(p. 80) into the bladder, and of preserving its parallelism. If this
part is too straight, running in the direction of the axis of the
main c annel from a to b, the instrument, after a few hours’ use,
wi revo ve on its own axis, and the end c may be turned to one
cu ?! T- en S °. far Tovmd as to impinge on the fistulous opening.
Should this accident happen, the instrument is not well suited to
Vesico- Vaginal Fistula 709
the case. It is either too long, too short, too crooked; or, what is
more likely, not curved down enough below the meatus.
When well fitted to the case, it can be worn with great ease to
the patient; and never turns, nor slips out, it matters not whether
she lies on the back or side. It is perfectly self-retaining, being
held in the bladder by an internal pressure against the symphysis
pubis, and by an external pressure on the outer end exerted by
the labia overlappping it, and hiding it entirely from view. The
holes should be small, about as represented in the drawing.
Thus, I have, as briefly as possible, described the mechanical
apparatus absolutely necessary for the successful treatment of
vesi co-vagi nal fistula.
Of the After-Treatment . — The operation finished, the patient is
placed in bed, and the catheter introduced into the bladder. A
moment will suffice to show the urine leaking from its outer
extremity.
A large anodyne should now be given, such as morphia, lau-
danum, paregoric, or whatever we may know will best agree with
the patient. The bowels are to be kept perfectly quiescent, till
the success or failure of the operation is ascertained. I have
often kept them locked up for three and four weeks without any
bad consequences whatever to the general system. In but two
instances, that I recollect, have I ever permitted them to be
opened under ten or fifteen days from the time of the operation.
This is very easily done. Previously to the operation some light
laxative medicine must be given: after it, the diet must be of a
constipating character. I generally direct my patients to live on
tea and crackers, allowing coffee if preferred, and prohibiting
meats, fruits, saccharine substances, and all articles of food made
of Indian, or common corn meal. Formerly, I allowed as little
water as possible; but latterly, since the introduction of silver
sutures, and the perfection of the catheter, I have not thought its
interdiction necessary. To assist the diet in producing constipa-
tion I order some form of opium in as large doses as can be borne,
at least twice in the twenty-four hours. Old fistula cases are
generally used to opium; and where they are not, they soon learn
its beneficial effects. It calms the nerves, inspires hope, relieves
y 1Q Medical Classics
the (p. 81) scalding of the urine, prevents a craving for food,
produces constipation, subdues inflammatory action, and assists
the patient, doomed to a fortnight’s horizontal position, to pass
the time with pleasant dreams, and delightful sensations, instead
of painful forebodings, and intolerable sufferings.
There is not the least necessity for the patient’s assuming the
erect posture, even for a moment: thus, by diet, opiates, and
quietude, a perfect state of constipation can be kept up as long
as we could possibly want it in any case. All this facilitates the
healing process, which is effected by the “first intention;” or,
if it fail, it does so only at one or two points, which may be
subsequently closed.
The catheter is to be removed as often as necessary to keep it
clear of concretions and mucus, which, in a few cases, may be
twice a day; in some, once; while in others, it may be allowed to
remain two or three days, or even longer. It is to be carefully
watched, and must not be permitted to remain long enough to
become obstructed. I have seen a failure result from a neglect
of this precaution.
The patient’s comfort is greatly promoted, by washing the
vulval opening twice a day, or oftener, with warm or cold water,
as may be preferred.
For this purpose a common bed-pan is placed under the nates,
as she lies on the back: when the water may be thrown into the
os externum, over the mons, vulva, and inguinal regions, by
means of a syringe holding some six or eight ounces. The water
has sometimes to be thrown with considerable force to remove the
urinary deposits from the nates and genitals.
The patient may lie on the back, or on either side, changing her
position whenever she pleases; but in no instance is she allowed
to raise up in bed.
Some women are more cleanly than others in protecting them-
selves and clothing from the urine. Most of them prefer old
cloths to absorb it, which are changed as frequently as necessary
for comfort.
On the third or fourth day after the operation, I usually ex-
amine t e sutures to see if all is right. This must be done with
Vesico-Vaginal Fistula 71 1
as little exertion on the part of the patient as possible. On the
sixth or seventh, I examine them again, and if they are doing no
mischief, it is much better not to remove them till the ninth or
tenth day. The removal of the clamps is occasionally trouble-
some, but by a little care it can be done with sufficient ease to
both patient and operator. The flattened shots are first clipped
off, then by a blunt hook, the anterior clamp is readily elevated
from its bed and removed; after which, the posterior one, with
the wires attached, may be hooked up, pushed backwards, dis-
engaged entirely, and then lifted out with the forceps.
This accomplished, place the patient in bed again, and con-
tinue the use of the catheter, with the recumbent position, for
several days longer, to prevent any strain or traction on the
delicate new cicatrix.
By allowing the patient to get up too soon, and evacuate the
contents of the bladder spontaneously, there is danger of ruptur-
ing the cicatrix, but by persevering with the catheter and position,
till it has time to become well organized, (p. 82) there is no danger.
This will take usually fifteen days from the performance of the
operation.
In other parts of the body, most surgeons have witnessed the
sudden disruption or gradual yielding of a freshly cicatrized
wound, which had been submitted to undue motion, or too strong
distention. A case of this kind recently occurred in my prac-
tice. A negro woman (aged 27) had a small tumour on the dorsal
aspect of the right thumb, involving the skin. It was removed
by two transverse elliptical incisions; the edges of the wound were
brought together and dressed with collodion, while the thumb
was bandaged to a straight splint to prevent any motion in the
joint or traction on the cicatrizing wound. It healed by the
first intention; the dressings were removed on the seventh day,
but the splint was continued on the palmar aspect of the thumb
for seven days longer. It was then laid aside, as I supposed the
cicatrix to be strong enough to resist the flexure of the thum
Everything went on well for three or four days longer, w en
the patient, who was a cook, suddenly lifting a boiling pot rom
the fire, was alarmed by the snapping asunder of the cicatrix on
yx 2 Medical Classics
the back of the thumb, -which made a noise so loud as to be heard
all over the room. The cicatrix had burst open through its
-whole extent; the blood flowed freely and the woman was greatly
frightened. It was dressed precisely as before; it healed up as
kindly; and by preserving the same precautions for a longer
time, the cicatrix remained permanently organized, the skin in
the neighbourhood yielding, and accommodating itself to the
motions of the thumb as perfectly as it ever did before any loss
of tissue. If such an accident as this can occur after eighteen
days of cicatrizing, we need not be surprised at the gradual or
sudden yielding of a cicatrix in the vagino-vesical structure in a
shorter space of time.
I have now completed what I have to say in a general way on
the subject of the operation for vesi co-vagi nal fistula. It re-
mains to detail individual cases, which will prove the curability
of the disease, and also illustrate the varieties and complications
to which it may be liable. The cases that occurred to me early
and which were given to me for the sake of experiment, will
show the difficulties that had to be overcome, the many dis-
appointments that had to be borne, and the ultimate success
that crowned my efforts after the perfection of the mechanical
contrivances; which, as it will be seen, was the work not of a day,
and the result, not of accident, but of long, laborious and per-
severing application.
But this communication has already reached to such an extent
that I must postpone the relation of my cases to a future op-
portunity.
MEDICAL CLASSICS
VOL. 2 April, 1938
NO. 8
CONTENTS
Portrait of Robert Koch - 714
Robert Koch
Biography - -- -- -- -- -- - 715
Eponyms - -- -- -- -- -- - 716
Introduction - -- -- -- -- -- 717
Bibliography of Writings ------- 720
Bibliography of Biographies - - - - - - 73 1
Untersuchungen liber Bacterien. Dr. Koch - - 745
Investigations of Bacteria. Dr. Koch - - - - 7^7
Die Aetiologie der Tuberculosis. Dr. Robert
Koch - - ----------- 821
The Etiology of Tuberculosis. Dr. Robert Koch - 853
MEDICAL CLASSICS
VOL. n April, 1938 K0 . 8
Robert Koch
BIOGRAPHY
1843 Born December 11, in Klausthal, the son of a mining
official of Hanover, the third of thirteen children.
Attended the Gymnasium of his native town.
1862 Age 19. Began his medical studies at Gottingen where
he was influenced by the teachings of Jacob Henle.
18 66 Age 23. Received the M.D. degree. Interned at the
Hamburg General Hospital.
1869 Age 26. Started practice in Rakwitz in Posen.
1870 Age 27. Volunteered for medical service during the
Franco-Prussian War.
1872 Age 29. Started practice in the town of Wollstein in the
District of Bomst in Polish Prussia; soon became Dis-
trict Physician.
1876 Age 33. Demonstrated the complete life cycle and spol-
iation of the anthrax bacillus and demonstrated for the
first time a specific microorganism as the cause of a
definite disease. Devised and developed many ingenious
methods of isolating, mounting and staining bacteria.
1 880 Age 37. Made a member of the Imperial Board of Health
by the German Government in recognition of the value
of his work. This enabled him to give up his country
practice and devote his time to research.
1881 Age 38. Introduced steam sterilization as more efficient
than the chemical sterilization advocated by Lister.
1882 Age 39. Announced his discovery of the bacillus of tuber-
culosis.
715
Medical Classics
1883 Age 40. As head of the German Cholera Commission,
" J visited Egypt and India. Discovered the cholera
vibrio. For his discovery of the bacillus of infectious
conjunctivitis, received 100,000 marks from the Prus-
sian State.
1885 Age 42. Appointed professor of hygiene and bacteriology
at the University of Berlin.
1890 Age 47. Introduced old tuberculin.
1891 Age 48. Director of the Institute for Infectious Diseases
at its founding in Berlin.
1896 Age 53. Investigated Rinderpest in South Africa at the
request of the English government. Studied Texas
fever, black-water fever, tropical malaria and plague.
1897 Age 54. Produced new tuberculin.
1898 Age 55. Studied malarial fever in Italy.
1902 Age 59. Studied Rhodesian red-water fever, horse-sick-
ness, trypanosomiasis and recurrent fever in German
East Africa.
I 9°5 Age 62. Received the Nobel Prize.
1906 Age 63. Studied sleeping sickness in Africa.
1910 Age 67. Died on May 27, of “heart failure.” Koch’s
body was cremated by his own wishes and the ashes
placed in the Berlin Institute for Infectious Diseases.
In appearance, Koch was a typical German savant of Prussian
cast, in character dignified, modest and fair-minded, altogether
one of the greatest men of science his country has produced.
(Garrison)
EPONYMS
Bacillus: The Bacillus tuberculosis.
Bacillus: The Koch-Weeks’ bacillus — found in acute infectious
conjunctivitis or Egyptian ophthalmia.
Law or Postulates or Circuit: The specificity of a microor-
ganism is not demonstrated without the fulfilment of the fol-
lowing conditions: (1) The microorganism is present and dis-
coverable in every case of the disease; (2) it is to be cultivated
7 17
Robert Koch
in. a pure culture; (3) inoculation from such culture must re-
produce the disease in susceptible animals; (4) it must be re-
obtained from such animals and again grown in a pure culture
(Dorland)
Lymph: See tuberculin.
Phenomenon : the sudden collapse of tuberculous animals when
a fresh culture of tubercle bacilli is injected within the peri-
toneum. The exudate that forms contains lymphocytes al-
most exclusively. (Dorland)
Reaction : The tuberculin reaction.
Spirocheta Kochi: A species found in cases of East Africa tick
fever.
Stain: Koch-Ehrlich’s stain or solution; consists of 100 parts of a
filtered aqueous solution of anilin oil, 10 parts of absolute al-
cohol, and 11 parts of a concentrated alcoholic solution of
fuchsin, methylene blue or gentian violet.
Streptococcus Kochi: A species from rabbits with artificial
septicemia.
Tuberculin: New; called also bacillen emulsion, emulsio bacilli
and tuberculin B. E. A form of tuberculin consisting of a
suspension of pulverized bacilli in water to which an equal
quantity of glycerin has been added.
Tuberculin: Old; the concentrated germ-free culture-medium
on which tubercle bacilli have been grown, then killed by heat
and filtered; the filtrate is concentrated by evaporation to
one-tenth of its volume.
INTRODUCTION
Robert Koch must have been born with unmeasurable ambition
and energy and an inspiration for solving scientific problems.
His childhood seems to have been an ordinary one except that he
was the third of thirteen children. In 1862, at the age of nine-
teen, he began his medical studies at Gottingen where he was in-
fluenced by the teaching of Jacob Henle who had proposed a
theory of contagion in 1840. Many people believed that Henle s
influence lead Koch to his researches in bacteriology. After
^ ?I 8 Medical Classics
receiving his medical degree Koch interned at the Hamburg
General Hospital and then started in medical practice. Koch
interrupted his practice by volunteering for medical service during
the Franco-Prussian War.
In 187a, at the age of twenty-nine, Koch finally settled down to
a medical practice in the town of Wollstein in the district of
Bomst in Polish Prussia. This town had a population of 4,000
people but Koch soon obtained the position of District Physician
so that his practice covered a large territory. In spite of long
hours of office practice and traveling into the outlying district,
Koch found and took time to carry on original research. At the
end of the room in which he received patients he rigged up a small
laboratory behind a curtain, provided himself with a microscope
and a few other necessities, and started to work. The first sub-
ject which drew his interest was the problem of an epidemic of
fever attacking the cattle of the region and endangering the
human population. Koch obtained some of the infected blood
from these animals and injected it into mice. By repeated exam-
ination with his microscope he saw that the bacteria in the sick
mice grew into long threads and changed under favorable con-
ditions into forms with spores. The bacteria were fairly easily
killed by sterilization but Koch found the spores resisted death
in a remarkable degree. Even after a long period of adverse
conditions, the spores were able to change themselves into an
active form and to transmit the disease to healthy animals.
Meanwhile, Ferdinand Cohn, Professor of Botany at Breslau,
was working with bacteria and had discovered that certain types
had the ability to form spores. Koch wrote to Cohn, telling
him of his findings and offered to demonstrate them. Cohn
gladly invited Koch to demonstrate the specimens before a group
of scientists, including Cohnheim, Weigert and Truabe, at the
Botanical Institute. There Koch’s experiments and conclusions
were enthusiastically received. Koch had proved the life cycle
of the anthrax bacillus and demonstrated for the first time a
specific microorganism as the cause of a definite disease. See the
o owing pages for Kochs paper on the anthrax bacillus which
is here reproduced in its entirety.
Robert Koch 719
For the next few years Koch busied himself in improving
methods of studying bacteria. He developed by his own in-
genuity several methods of isolating, mounting and staining or-
ganisms to be examined under the microscope. He also worked
assiduously with the photography of microorganisms. During
this same period he introduced steam sterilization as more efficient
than the use of chemicals which had been popularized by Lister.
Other important work of Koch was the use of solid media for
growing bacteria in pure culture. Koch demonstrated methods
of bacterial isolation and culture before the International Con-
gress of Medicine held in London in 1891 and the great Pasteur, as
the leader of the bacteriologists, recognized the importance of
Koch’s work and praised him highly.
In 1880 Koch’s work was recognized by the German Govern-
ment and he was made a member of the Imperial Board of Health,
thus relieving him of the necessity of carrying on his small coun-
try practice.
On March 24th, 1882, at a meeting of the Berlin Physiological
Society, Koch announced the discovery of the bacillus of tuber-
culosis. This work is the greatest and best known of all of Koch’s
labors. The organism requires a special media and proper con-
ditions for its growth in culture and a unique staining method for
its observance. In contrast to the difficulty of staining and grow-
ing the organism, Koch showed that, after it was injected into
certain laboratory animals, tuberculosis was readily produced.
Koch then formulated the postulates or law which has ever since
been known by his name. (See eponyms.) For this work, in
the face of the teaching of the day that tuberculosis was the result
of nutritional disturbances, Koch took his place as the greatest
bacteriologist of his day and as one of the great physicians of all
time. By the discovery of the actual cause of tuberculosis real
scientific progress was possible toward controlling this widespread
and terrible affliction. For this discovery of the bacillus of
tuberculosis, Robert Koch received the Nobel Prize in 1905.
Koch’s paper of 1882 announcing the discovery of the bacillus of
tuberculosis is included in this number.
720 Medical Classics
BIBLIOGRAPHY OF WRITINGS
A. Army Medical Library.
B. New York State Library.
C. New York Academy of Medicine Library.
D. Kings County Medical Society, Brooklyn, Library.
E. Lane Medical Library of Stanford University.
F. John Crerar Library, Chicago.
1. Ueber das Vorkommen von Ganglienzellen an den Nerven
des Uterus. Eine von der medicinischen Fakultat zu
Gottingen gekronte Preisschrift. (On the presence of
ganglion cells on the nerves of the uterus. A prize paper
to the Medical Faculty of Gottingen.) Gottingen, Kaest-
ner, 1865, 4 0 , 19 pp., 3 pi. In A., F.
2. Die Aetiologie der Milzbrandkrankheit, begriindet auf die
Entwicklungsgeschichte des Bacillus Anthracis (1876).
(The etiology of anthrax based on the developmental
history of the anthrax bacillus.) Beitr. z. Biol. d. Pflanz.,
2: 277-310, 1877. Also: Mitth. a. d. k. Gesundheitsamte.,
1: 49-79, 1881. Also No. 9 of Klassiker der Medizin,
Sudhoff, Leipzig, Barth, 1912. 12 0 , 47 pp., 1 p. In
A, C, E, F.
3. Untersuchungen uber Bacterien. VI. Verfahren zur Unter-
suchung, zum Conserviren und Photographiren der Bac-
terien. (Investigations of bacteria. VI. Procedure of
research, to preserve and photograph bacteria.) Beitr.
z. Biol. d. Pflanz., 2: 399-434, 1877.
4. Ueber die practische Bedeutung des Zahndurchbruchs.
(On the practical significance of dentition.) Brief note
before the Verhandl. aerztliche Gesellsch., 1877. Berl.
klin. Woch., 14: 694 only, 1877.
5. Untersuchungen fiber die Aetiologie der Wundinfections-
krankheiten. (Investigations into the etiology of trau-
matic infective diseases.) Leipzig, Vogel, 1878. 8°,
8° pp., 5 pi. In A, C, D, F. Also, trans. by W. W.
Cheyne. London, New Sydenham Soc., 1880. 8°, xiii,
74 PP-5 5 pl. In A, C, D, E, F.
Robert Koch
?2i
6. Zur Lehre von den Gelenk neuralgien. (On the warning of
joint neuralgia.) Brief note before the Congr. d. deut.
Gesellsch. f. Chir. Berl. klin. Woch., 15: 356-357, 1878.
7. Fehlen der Milz. (Absence of the spleen.) Ibid., 16:
81-82, 1879.
8. Uber Aphasie auf anamischen Boden. (Aphasia on an
anemic basis.) Ibid., 105-107, 1879.
9. Uber die Wirkung der Oxalate auf den thierischen Organis-
mus. (On the effect of oxalate on the animal organism.)
Dorpat, 1879. 8°. Also: Arch. f. exper. Path. u. Phar-
makol., 14: 153-199, 1881.
10. Ein zweiter Fall von Aphasie ex Anamia. (A second case
of aphasia due to anemia.) Berl. klin. Woch., 17: 229-
230, 1880.
11. Die Frage der Curpfuscherei. (The question of quackery.)
Aerztl. Int.-Bl., Miinchen, 27: 295; 309, 1880.
12. Zur Untersuchung von pathogenen Organismen. (The
investigation of pathogenic organisms.) Mitth. a. d. k.
Gesundheit., I: 1-48, 14 pi., 1881. Also, trans. By V.
Horsley, in W. W. Cheyne’s Recent essays on bacteria.
London, 1886, pp. 3-64. In A, B, C, D.
13. Untersuchungen uber die Desinfection mit heisser Luft.
(Investigations on disinfection with hot air.) With G.
Wolfhugel. Mitth. a. d. k. Gesundheit., 1: 301-321,
1881. Also, in W. W. Cheyne’s recent essays on bacteria.
London, 1886. pp. 519-525.
14. Uber Desinfection. (On disinfection.) Mitth. a. d. k.
Gesundheit., I: 234-282, 1881. Also, trans. and abstr.
by B. A. Whitelegge in W. W. Cheyne’s Recent essays on
bacteria. London, 1886. pp. 493-518.
15. Versuche uber die Yermerthbarkeit heisser Wasserdampfe
zu Desinfectionszwecken. (Experiment on the value of
steam for disinfecting purposes.) With G. Gaffky and
F. Loffler. Mitth. a. d. k. Gesundheit., 1: 322-340, 1881.
Also, in W. W. Cheyne’s Recent essays on bacteria.
London, 1886. pp. 526-533.
16. Entgegnung auf den von Dr. Grawitz in der Berliner medi-
722 Medical Classics
cinischen Gesellschaft gehaltenen Vortrag liber die Anpas-
sungstheorie der Schimmelpilze. (Reply to the discourse
on the adaptation theory of hyphomycetes, given to the
Berlin Medical Society by Dr. Grawitz.) Berl. klin.
Woch., 1 8: 769-774, 1881.
17. tlber die Milzbrandimpfung. Eine Entgegnung auf den
von Pasteur in Geuf gehaltenen Yortrag. (On inoculation
for anthrax. A reply to the lecture given by Pasteur in
Geuf.) Kassel, u. Berlin, Fischer, 1882. 8°, 37 pp.
In A, C, F. Same, in French, Semaine med., Paris, 2:
205; 209, 1882. Same, Kassel, u. Berlin, Fischer, 1883.
8°, 40 pp. In A. C. Same, in French, Rev. scient.,
Paris, 31: 65-74, 1883.
18. Die Aetiologie der Tuberculose. (The etiology of tuber-
culosis.) Berl. klin. Woch., 19: 221-230, 1882. Also:
Berlin, 1882. 8°, 29 pp. In A. Also: Med.-Chir.
Centralbl., 17: 278; 302; 326; 351 ; 363; 375, 1882. Also:
Arch. f. Physiol., pp. 190-192, 1882. Also: Verhandl. d.
Cong. f. innere Med., 1 : 56-79, 1882. Also: Gior. internaz.
d. sc. med., Napoli, n.s. 4: 702-716, 1882. Also: trans.
by W. D. Oakley. Canada M. and S. Jour., 10: 649-655,
1882. Also: trans. by J. Eichberg. Cincinnati Lancet
and Clinic, n. s. 10: 428-439, 1883. Also, with introduc-
tion by M. Kirchner, in Klassiker der Medizin, No. 19,
Leipzig, Barth, 1912. 12 0 , 74 pp. In A, C, E, F. Also:
trans. by Berna and Max Pinner. Amer. Rev. Tuber.,
25: 298-323, 1932, and Nat. Tuber. Assoc., 1932. 26 cm.,
48 pp., 8 illust.
19. Bericht der nach Egypten entsendeten deutschen Cholera-
Commission. (Report of the German Cholera Commis-
sion in Egypt.) Mitth. d. Ver. d. Aerzte in Nied.- Oest.,
9: 258-264, 1883. Also: Wien. med. Bl., 6: 1245-1250,
1883; 7: 464, 1884. Also: Allg. med. Centr.- Zeitg., 1883.
Also: Wien. med. Woch., 33: 1248-1252; 1548-1551,
1 ^83 ; 34: 443-446, 1884. Also: Breslau, aerztl. Zeitschr.,
5: 215-218, 1883; 6: 99, 1884. Also, trans.: Med. Times
and Gaz., London, 2: 447, 1883.
Robert Koch 723
20. Kritische Besprechung der gegen die Bedeutung der Tuberkel-
bacillen gerichteten Publicationen. (Critical reply to
the publications directed against the significance of the
tubercle bacilli.) Deutsche med. Woch., 9: 137-141,
1883. Also: Berlin, Reimer, 1883. 8°, 17 pp. In A.
Also: Allg. Wien. med. Zeitg., 28: 105; 119, 1883. Also:
Wien. med. Bl., 6: 325; 358, 1883. Also: Oesterr. arztl.
Vereinszeitg., 7: 43; 51, 1883. .
21. Der Seitens des — an den Staatssecretar des Innem erstaatete
Bericht. (The side of the — report to the State Secretary
of the Innern erstaatete Bericht.) Deutsche med. Woch.,
9: 615-617, 1883. Also: Deutsche Vrtljschr. f. off.
Gesundths., Bruschwg., 16: 493-515, 1884.
22. Die Aetiologie der Tuberculose. (The etiology of tubercu-
losis.) Mitth. a. d. k. Gesundheit., 2: 1-88, 10 pi., 1884.
Also, trans. and abstr.: Phila. Med. Times, 14: 542-545,
1884. Also, trans. by S'. Boyd, in W. W. Cheyne’s recent
essays on bacteria. London, 1886. pp. 67-201. Also,
trans. by F. Saure: Amer. Vet. Rev., 13: 54-82; 104-130;
148-171; 1 97-214, 1889, a °d New York, Jenkins, 1890.
8°, 97 pp. In C. Also: New York Journal and Adver-
tiser, 1901, and New York, 1901, 8°, 10 pp., II. In A, C.
23. Experimented Studien fiber die kfinstliche Abschwachung
der Milzbrandbacillen und Milzbrandinfection durch Ffit-
terung. With Gaffky and Loeffler. (Experimental stud-
ies on the artificial attenuation of the anthrax bacillus and
infection with anthrax through fodder.) Mitth. a. d. k.
Gesundheit., 2: 147-181, 1884.
24. Die Beziehungen der Tuberkelbacillen zur Aetiologie der
Tuberkulose. (Relations of the tubercle bacillus to the
etiology of tuberculosis.) Med.-Chir. Centralbl., 19:
50, 1884.
25. Discussion on Conferenz zur Erorterung der Cholerafrage.
(Discussion on conference for debate of the cholera ques-
tion.) Berl. klin. Woch., 21: 478-483, 1884. Also, transl.
by G. L. Laycock in W. W. Cheyne’s Recent essays on
bacteria. London, 1886, pp. 327-384. Also, transl.:
Brit. M. J., 1: 6; 62, 1886.
Medical Classics
7 2 4
26. Ueber die Cholera mit besonderer Riicksicht auf dieComma-
bacillen. (On cholera, with special reference to the comma
bacillus.) Wien. med. Bl., 7: 991; 1023; 1062; 1094, 1884.
27. Ueber die Entstehungsursache der asiatischen Cholera.
(On the source of Asiatic cholera.) Med.-Chir. Centralbl.,
19:424, 1884.
28. II Cholera. Gazz. Med. ital. lomb., 8 s. 6: 353; 417; 465,
1884.
29. Was wissen und konnen unsere Aerzte? Ueber Naturheilung
und medicinische Kunst. (What do our physicians know
and what can they do? On natural healing and the art
of medicine.) Leipzig, Hucke, 1885. 8°. 2 Aufl. Leip-
zig, Hucke, 1885. 8°, 88 pp. In A, F.
30. Die Cholera auf ihren neusten Standpunkte. (Cholera from
the newest point of view. Berlin, Hampel, 1886. In E.
31. Berich uber die Untersuchungen des Berliner Leitungs-
wassers in der Zeit vom I. Juni 1885 Apr. 1886,
ausgefuhrt im hygienischen Institut der Universitat
Berlin. (Report on the investigation of Berlin conduit
water from June 1, 1885 to April 1, 1886, carried on in
the Institute of Hygiene of the University of Berlin.)
Berlin, Springer, 1887. 8°, 50 pp.
32. Die Bekampfung der Infektionskrankheiten, insbesondere
der Kriegsseuchen. Rede gehalten zur Feier des Stif-
tungstages der militararztlichen Bildungs-Austalten am
2. August 1888. (The control of the infectious diseases,
especially war epidemics. Speech given on the celebra-
tion of the founding of the Army Medical School.) Ber-
lin, Hirschwald, 1888. 8°, 40 pp. In A, C, E. Same,
rev.: Wien. Med. Bl., 11: 1306; 1371, 1888. Also: Mili-
tararzt, Wien, 22: 177; 185; 194; 209, 1888. Also, in
Russian, St. Petersburg, 1889. 8°, 100 pp. In A. (Same)
La prophylaxie des maladies infectieuses dans les armees.
Transl. in Rev. scient. Par., 42: 561-568, 1888.
33 - Ueber bakteriologische Forschung. (Bacteriological investi-
gation.) Wien. med. BL, 13: 531-535, 1890. Also:
Verhandl. d. X internat. med. Cong., 1 890,’ Berl., 1 : 35-47,
Robert Koch
725
1891. Also: Berlin, Hirschwald, 1890. 8°, 15 pp. In
A, C. Also, transl.: Brit. M. J., 2: 380-383, 1890. Also,
transl. in Russian, 1890. In A. Also, transl.: On bac-
teriology and its results. By T. W. Hime. London,
Balliere, 1890. 8°, 23 pp. In A. Also, transl. : Advances
in bacteriology; an address. Wood’s Med. and Surg.
Monog., 9: 1-13, 1891. In A, E. Also: In Klassiker der
Medizin, No. 9, Leipzig, Barth, 1912. ia°, 74 pp. In
A, C, E, F.
34. Weitere Mittheilungen iiber ein Heilmittel gegen Tuber-
culose. (Further communications on a remedy for tuber-
culosis.) Deutsche med. Woch., 16: 1029-1032, 1890;
17: ioi; 1189-1192, 1891. Also: Berl. klin. Woch., 27:
1077-1080, 1890; 28: 77-78, 1891. Also: Centralbl. f.
allg. Gesundheitspflg., Bonn, 9: 385-395, 1890. Also:
Heft 1-3, Berlin u Leipzig, Thieme, 1890. Also, transl.:
Lancet, Lond., 2: 1085, 1890; 2: 976-979, 1891. Also,
transl.: Brit. M. J., 2: 1193-1195", 1890'; I: 125-127, 1891.
Also, transl.: Med. News, Phila., 57: 521-527, 1890.
Also, transl.: Bull, med., Par., 4: 1009-1012, 1890. Also,
transl.: Pest, med.-chir. Presse, Budapest, 24: 1105-1111,
1890. Also, transl.: Ann. Soc. med.-chir. de Liege, 29:
446-456, 1890. Also, transl.: Med. Rec., N. Y., 38: 734,
1890; 39: 55, 1891. Also, transl.: Sicilia med., Palermo,
2: 890-8963 1890. Also, transl.: Montreal Med. St., Dec.
1890. Also, transl.: London, Heinemann, 1890. 8°,
32 pp. In A, C. Also, transl. in Swedish, 1890. In A.
Also: Wien. med. Woch., 41: 1721-1724, 1891. Also,
transl.: Semaine med., Paris, 11: 17? 1891. Also, transl.:
In Prof. Koch’s method to cure tuberculosis popularly
treated by Max Birnbaum. Milwaukee, Harper, 1891.
8°, 27 pp. Also, transl. by E. Tutzscher, Paris, Hin-
richsen, 1891. 12 0 , 114 pp. Also: In Klassiker der
Medizin, No. 19, Leipzig, Barth, 1912. 12 0 , 74 pp.
In A, C.
35 * Zur Casuistik der Bronchitis fibrinosa. (Case description
of fibrinous bronchitis.) St. Petersb. med. Woch., 9:
83-85, 1892.
Medical Classics
726
36. Ueber Magenblutungen in der Graviditat. (On gastric
hemorrhage in pregnancy.) Ibid., 10: 89, 1893. Also:
Med.-chir. Centralbl., Wien, 28: 297, 1893.
37. Ueber das Carcinoma yentriculi ex ulcere rotundo. (On
carcinoma of the stomach arising from peptic ulcer.)
St. Petersb. med. Woch., 10: 385-387, 1893. Also:
Med.-chir. Centralbl., Wien, 29: 1-3, 1894.
38. Entgegnung auf den Vortrag des Herr Professor Dr. M,
Schottelius: Zum mikroskopischen Nachweis von Cholera-
bacillen in Dejectionen. (Reply to the lecture of Prof.
Dr. M. Schottelius: On the microscopic demonstration of
cholera bacilla in dejecta.) Deutsche med. Woch., 19:
739> 18 93 •
39. Revolverkugel in den Mund. (On gunshot wound in the
mouth.) Berk klin. Woch., 30: 246 only, 1893.
40. Ueber den augenblicklichen Stand der bakteriologischen
Choleradiagnose. (The present state of bacteriological
diagnosis of cholera.) Zeitschr. f. Hyg. u. Infect., 14:
319-338, 1893. Also, rev.: Berl. klin. Woch., 30: 585— 58 6,
1893. Also: Wien. med. Bl., 16: 305; 317; 340, 1893.
Also, transl.: Semaine med., Par., 13: 265-268, 1893.
Also, transl.: Med. Week., Par., 1: 265-269, 1893.
Also, transl.: Practitioner, London, 51: 466-476, 1893.
41. Wasserfiltration und Cholera. (Filtration of water and
cholera.) Zeitschr. f. Hyg. u. Infect., 14: 393-396, 1893.
Also, crit.: Berl. klin. Woch., 30: 896-898, 1893. Also,
transl. by A. J. A. Ball, London, 1893. 19 pp., fol. In
A. Also: Practitioner, London, 51 : 146; 218, 1893. Also:
Rep. Local Gov. Bd., 1892-1893, London, 22: 439-462,
1894. Also, transl.: Semaine med., Par., 13: 305-309,
7893.
42. Die Cholera in Deutschland wahrend des Winters 1892 bis
1893. (Cholera in Germany during the winter of 1892-
1893.) Zeitschr. f. Hyg. u. Infect., 15: 89-165, 1893.
Also, crit.: Berl. klin. Woch., 30: 1103-1104, 1893.
Also, transl.: Lancet, Lond., 2: 828; 891, 1893. Also,
transl. by George Duncan. Edinburgh, Douglas, 1894.
Robert Koch
727
8°, 150 pp. In A, F. Same, New York, Jenkins, 189c.
In D.
43. Vorlesungen iiber cholera. (Lecture on cholera.) Wien.
med. Bl., 16: 327-329; 353; 366; 378, 1893.
44. Beobachtungen iiber Erysipel-Impfungen am Menschen.
(Observation on the inoculation of erysipelas in man.)
Zeitschr. f. Hyg. u. Infect., 23: 477-489, 1896.
45. Die Lepra-Erkrankungen im Kreise. (The course of leprosy.)
Memel. klin. Jahrb., Jena, 6: 239-253, 1897.
46. Ueber neue Tuberkulinpraparate. (On new tuberculin.)
Deutsche med. Woch., 23: 209-213, 1897. Also: AUg.
Wien. med. Ztg., 42: 165; 177; 199; 21 1, 1897. Also,
transl.: Med. mod., Par., 8: 218-228, 1897. Also, transl.:
Med. Week, Par., 5: 169-172, 1897. Also, transl.: Presse
med., Par., 5: 159-160, 1897. Also, transl.: Rev. de
therap. med.-chir., Par., 44: 249-259, 1897. Also, transl.
in Russian, Moscow, 1897. 8°, 12 pp. In A.
47. Berichte des Prof. Dr. Koch iiber seine in Kimberly gemach-
ten Versuche beziiglich Bekampfung der Rinderpest.
(Dr. Koch’s report on his attempt to control cattle plague
in Kimberly.) (Transl. from: Agricult. J., Capetown)
Centralbl. f. Bakteriol., 1. abt., 21: 5 2 -6— 537, 1897.
48. Special report on researches into the cause of cattle plague.
Brit. M. J., 1: 1245, 1897.
49. Aerztliche Beogachtungen in den Tropen. (Medical obser-
vations in the tropics.) Deutsche kolonial-gesellschaft.
Abt. Berlin. Charlottenburg Verhandlungen, Hft. 7, 1897.
Also: Berlin, Reimer, 1898. 8°, pp. 280-317. Also:
Wien. med. Zeitg., 43: 381; 391, 1898. Also, transl.:
Ann. d’hyg. et de med. colon.. Par., 1: 368-39^ 1898.
Also, transl.: Rev. scient., Par., 4. s. 10: 777; 812, 1898.
50. Reise-Berichte iiber Rinderpest, Bubonenpest in Indien und
Afrika, Tsetse-oder Surrakrankheit, Texas-fieber, tropische
Malaria, Schwarzwasserfieber. (Travel-report on cattle
plague, bubonic plague, in India and Africa, tsetse or
surra, Texas fever, tropical malaria, black water fever.)
Berlin, Springer, 1898. 8°, 136 pp. 1 p.l. In A, C.
728 Medical Classics
51. Die Malaria in Deutsch-Ostafrika. (Malaria in German
East Africa.) Arb. a. d. k. Gusdhtsamte, 14: 292-304,
1898.
52. Das Schwarzwasserfieber. (Black-water fever.) Ibid., 14:
304-308, 1898.
53. Ueber die Verbreitung der Bubonenpest. (On the trans-
mission of bubonic plague.) Deutsche med. Woch., 24:
437-439, 1898. Also: Miinchen med. Woch., 44: 91 1-
913, 1898.
54. Diagnosis, treatment and prophylaxis of tropical malaria.
Transl. by E. O. Shakespeare. Philadelphia, 1898. 24°,
38 pp. In C.
55. Tropenhygiene und Tropenkrankheiten. Zweiter Bericht
uber die Thatigkeit der Malaria-Expedition. Aufenthalt
in Niederlandisch-Indien vom 21 September bis 12 Decem-
ber 1899. (Tropical hygiene and tropical diseases. Second
report on the accomplishment of the Malaria Expedition.
Stay in Dutch India from September 21 to December 12,
1899. ) Deutsche med. Woch., 26: 296-297; 397-398;
541-542; 27: 88-90, 1900.
56. The study of malaria in Rome. Med. Rec., N. Y., 57: 294,
1900. Also: Riforma med., Palermo, i: 505-506, 1900.
Also: Rev. balear de Cien. med., Palma de Mallorca, 18:
56-65, 1900.
57. Zusammenfassende Dorstellung der Ergebnisse der Malaria-
expedition. (Composite presentation of the results of the
Malaria Commission.) Deutsche med. Woch., 26: 781-
783; 801-805, 1900.
58. Ergebnisse der vom Deutschen reich ausgesandten Malaria-
expedition. (Results of the malaria expedition sent out
from Germany.) Berlin, Reimer, 1900. 8°, 27 pp. In C.
59. Ueber die Bekampfung der Tuberkulose. (On the control
of tuberculosis.) Allg. Wien. med. Zeitg., 46: 360-361,
1901. Also: Deutsche med. Woch., 27: 549-554, 1901.
60. On the transference of bovine tuberculosis to man. Brit.
M. J., 2: 1885-1889, 1902. Also: Vet. J., London, n.s.,
7: 8-19, 1903. '
Robert Koch
729
61. Die Bekampfung des Typhus. (The control of typhus.)
Berlin, Hirschwald, 1903. 8°, 22 pp. Forms Heft 21 of
Veroffentl. a. d. Geb. d. Mil.-San.- Wes. In A, C.
62. Die Bekampfung der Malaria. (The control of malaria.)
Zeitschr. f. Hyg. u. Infect., Leipzig, 43: 1-4, 1903.
63. Revision of Alfred Hillier’s The prevention of consumption.
London, Longman, 1903. 12 0 , 240 p., 1 pi., 1 ch.
64. Ueber die Trypanosomenkrankheiten. (On the trypanosoma
diseases.) Munchen. med. Woch., 51: 1987, 1904. Also:
Deutsche med. Woch., 30: 1705-1711, 1904. Also: Berl.
tierarztl. Woch., pp. 736-739, 1904. Also, transl.: Brit.
M. J., 2: 1445-1449, 1904.
65. Vorlaufiger Bericht fiber das rhodesische Rotwasser oder
afrikanische Kiistenfieber. (Preliminary report on Rho-
desian redwater or African coast fever.) Arch. f. wis-
sensch. u. prakt. Tierh., Berl., 30: 281-319, 1904. Also,
transl.: Vet. Rec., London, 16: 507-51 1, 1904.
66. Ueber die Immunisierung von Rindern gegen Tuberkulose.
With W. Schutz et al. (On the immunization of cattle
against tuberculosis.) Arch. f. wissensch. u. prakt. Tierh.,
31: 545-575, 1905. Also: Zeitschr. f. Hyg. u. Infect., 51 :
300-327, 1905.
67. A few observations on relapsing fever. Med. News, 87:
1127-1129, 1905.
68. Vorlaufige Mitteilungen fiber die Ergebnisse einer For-
schungsreise nach Osafrika. 1. Recurrens. 2. Entwick-
lung des Piroplasma bigeminum. 3* Kiistenfieber der
Rinder. 4. Tsetsefliegen und Trypanosoma. (Prelimi-
nary contributions on the results of a journey of investiga-
tion to East Africa. 1. Recurrent fever. 2. Develop-
ment of Piroplasma bigeminum. 3- Coast fever of cattle.
4. Tsetse flies and trypanosoma.) Deutsche med. Woch.,
31: 1865-1869, 1905. Also, transl.: J. Trop. Med., 9: 43;
75; !°4; I37> „
69. Uber den derzeitigen Stand der Tuberkulosebekampfung.
(The present state of control of tuberculosis.) Lecture
at presentation of Nobel Prize. Les Prix Nobel, pp. 1 - 12,
730 Medical Classics
1905. Also: Nord. med. Ark., Stockholm, 3. f., 5, afd. 2,
No. 13, 1-13, 1905. Also: Deutsche med. Woch., 32: 89-
92, 1906. Also: Zeitschr. f. Tuberk., 8: 91-100, 1906.
Also, transl.: Lancet, London, I: I449-I451, 1906. Also,
transl.: Clin. mod., Zaragoza, 5: 273-281, 1906.
70. BeitragezurEntwicklungsbeschichtederPiroplasmen. (Con-
tributions to the development of piroplasmus.) Zeitschr.
f. Hyg. u. Infect., 54: 1-9, 1906.
71. Ueber therapeutische Verwendung von Tuberkulin. (On
the therapeutic application of tuberculin.) Med. Woch.,
Halle, 7: 493-496, 1906.
72. Ueber die Rolle der Milch bei der Uebertragung der Tubercu-
lose auf Menschen. (On the role of milk in the trans-
mission of tuberculosis to humans.) Molkerei-Zeitz., 16:
37, 1906.
73. Ueber afrikanischen Recurrens. (African recurrent fever.)
Berl. klin Woch., 43: 185-194, 1906. Also, abstr.: Med.
Bl., 29: 1 1 8, 1906. Also, abstr.: Deutsche med. Woch.,
32: 283, 1906. Also, transl.: Post-Graduate, New York,
21: 770-789, 1906.
74. Ueber den bisherigen Yerlauf der deutschen Expedition zur
Erforschung der Schlafkrankheit in Ostafrika. (On the
course to date of the German Expedition for the investiga-
tion of sleeping sickness in East Africa.) Deutsche med.
Woch., 32, pp. 1-8, 1906. Also: Berlin, Bernstein, 1906.
4°, 7 pp. In A.
75. Bericht uber die Statigkeit der deutschen Expedition zur
Enforschung der Schlafkrankheit bis zum 25. Novem-
ber 1906. ((Report on the progression of the German
expedition to investigate sleeping sickness to November
25, 1906.) Deutsche med. Woch., 33: 49-51; 1462;
1889-1895, 1907. Also: Berl. klin. Woch., 44: 1523-1527,
1907. Also: Berlin, Reimer, 1908. 8°, 47 pp. In C.
Also, with M. Beck and F. Kleine: Arb. a. d. k. Gesund-
heit., 31: 1-319, 1909.
76. Im Dienst des Roten Kreuzes; Erinnerungen. (A tribute to
the Red Cross; recollections.) Deutsche Rev., 1 : 338-
348, 1909.
Robert Koch
73 1
77. Antrittsrede in der Akademie der Wissenschaften am 1.
Juli 1909. (First address at the Academy of Science on
July I, 1909.) Deutsche med. Woch., 35: 1278, 1909.
78. Zur medikamentosen Behandlung der Lungentuberkulose.
(On the medical treatment of tuberculosis of the lungs.)
Therap. Rundschau, Berl., 3: 101-103, 1909.
79. Foreword to Bandelier and Roepke’s Lehrbuch der spezifis-
chen Diagnostik und Therapie der Tuberkulose, — .
Wurzburg, 1910. In D.
80. Epidemiology of tuberculosis. Smithsonian report for 1910.
Zeitschr. f. Tuberk., 16: 1 15-135, 1910. Also: Smith-
sonian Institution Pub., No. 2049, 1911.
81. Gesammelte Werke; unter Mitwirkung von G. Gaffky und
E. Pfuhl hrsgb. von J. Schwalbe. (Collected Works; in
association with G. Gaffky and E. Pfuhl, edited by J.
Schwalbe. Leipzig, Thieme, 1912. 2 v. in 3. fol. In
A, C, D, E, F.
BIBLIOGRAPHY OF BIOGRAPHIES
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Geheimrat Koch in der Deutschen Warte. Deutsche Wate,
1890.
Biography by T. P. A. Stuart. Australas. Med. Gaz. 10: 249-
255, 1890-1891.
Bei Robert Koch. By P. Lindenberg. Leipzig, 1891. 4 0 .
Aus der Familienchronik von Robert Koch. By R. Viemend.
Deutsche Rev., 16: 87; 219, 1891.
Koch’s injections for actinomycosis. By T. Billroth. Wien,
klin. Woch., 10, 1891.
Biography by W. Becker. Berlin, 1891, 3 Aufl., 8°.
Biography. Prov. Med. Jour., Leicester, 10: 1, 1891.
Koch’s contributions to tuberculin. By F. Hueppe. Berl. klin.
Woch., 28: 1121-1122, 1891.
Koch’s visit to South Africa. South African Med. Jour., 4:
211-214, 1896-1897.
7 'I?, M cd 5 cal Glass* cs
Hy/%rzphy. Mod. Mod,, I'am, 7; ouppb, JO9, 7^9(3,
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Ktnvffini'.vfet von Pobert Koch m Tokyo, Juno 1 6, 3 90#,
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bkotch in hi or: chon mod. Wod),, 55; 2253, 7 yA,
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7930,
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443 ' 449 . I'J/o.
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PA'/yf'dphy by 3, Jielfunti. Tuboreuloei, Milano, 3; 7-74, 7970-
7977,
Robert Koch 733
Biography by Y. Ellermann. Ugesk. f. Laeger, 72: 644-648,
1910.
Biography by M. Kirchner. Zeits. f. Tuberk., 16: 105-114,
1910.
Biography by A. Netter. Compt. rend. Soc. de biol., Paris, 59:
1-6, 1910.
Biography by Meinicke. Deutsche Aerzte-Zeitg., 39: 265-267,
1910.
Necrology. By B. Mollers. Ibid., 39: 473-478, 1910.
Biography by G. Gaffky. Deutsche med. Woch., 36: 2321-
2324, 1910.
Biography by J. Bordet. Jour. med. de Brux., 15: 373-377,
1910.
Biography by G. S. Woodhead. Jour. Path, and Bacteriol.,
Cambridge, 15: 108-114, 1910-1911.
Biography. Lancet, London, i: 1583-1588, 1910.
Krankheitsgeschichte Robert Koch’s. By L. Brieger and F.
Kraus. Deutsche med. Woch., 36: 1045,1910.
Der Anteil Kochs an der Malaria-forschung. By R. Ruge.
Malaria. Internat. Arch., 2: 168-170, 1910.
Obituary. Brit. Med. Jour., 1: 1384-1389, 1910.
Biography by P. Ehrlich. Chicago Med. Recorder, 32: 443-450,
1910.
Biography by R. Pfeiffer. Berl. klin. Woch., 47: 1045-1048,
1910.
Sketch by S. A. Knopf. Tuberculosis, 1910.
Robert Koch and his achievements. Editorial. Jour. Amer.
Med. Assn., 54: 1772-1876, 1910.
Sketch by E. Pfuhl. Deutsche med. Woch., 37: 1399; 14435
1483; 1524, iglJ; 3: 182-199, 1911; Also: Deutsche Rev.,
38: noi; 1148; 1195, 1912.
The life and work of Koch. By W. W. Ford. Johns Hopkins
Hosp. Bull., 22: 415-425, 1 91 1.
Koch, the father of the modern science of tuberculosis. By S.
A. Knopf. Ibid., 22: 425-428, 1911.
Memorial address by J. A. Wyeth. Med. Rec., 79: 95 ~ 97 > I 9 11,
Also; Amer. Jour. Obst., 63: 482-484, 1911.
Medical Classics
734
The discovery of the tubercle bacillus. By A. T. Laird. Alb.
Med. Ann., 32: 311-318, 1911.
Gedachtuisrede auf Robert Koch. By G. Gaffky. Tuberculosis,
Berlin, 10: 1-1 2, 1911.
Biography by K. Wezel. Berlin, Hirschwald, 1912. 8° roy.
156 pp.
Robert Koch’s Entwicklung zum bahnbrechenden Forscher. By
Pfuhl. Deutsche Rev., 2: 338-356, 1912.
Robert Koch zum Gedachtnis. By J. Schwalbe. Deutsche med.
_ Woch., 39: 157; 2441; 2468, 1913.
Erinnerungen aus der Zeit der atiologischen Tuberkulosefor-
schung: Robert Koch. By P. Ehrlich. Ibid., 39: 2444-
2446, 1913.
Robert Koch und das Spezifitatsproblem. By W. Kolle. Ibid.,
39: 2446-2448, 1913.
Zur Erinnerung an Robert Koch. By W. Kolle. Med. Klin.,
9 : 2I 375 2 *59> 1 9 ] 3 -
A monument to Koch in Japan. Editorial. Jour. Amer. Med.
Assn., 62: 213, 1914.
Dem Andenken Robert Koch. By G. Gaffky. Deutsche med.
Woch., 42: 653-655, 1916.
Sketch by F. Neufeld. Zeits. f. arztl. Fortbild., 13: 349, 1916.
Sketch. Jour. Amer. Med. Assn., 67: 1953, 1916.
Enthiillung des Robert Koch — Denkmals. Deutsche med.
Woch., 42: 704, 1916.
Biography by H. C. Ernst. Proc. Amer. Acad. Arts and Sc.,
53: 825-827, 1918.
Essays on tuberculosis. III. Robert Koch. By A. K. Krause.
Jour. Outdoor Life, 15: 97-101 ; 101-109; 120, 1918.
Medical reminiscences; a call upon Robert Koch in his laboratory
in 1902. By E. R. Baldwin. Jour. Outdoor Life, 16: 302,
I 9 I 9-
Biography. Med. Life, 29: 207, 1922; 31: 352-370, 1924; 39:
164, 1932.
Biography. Med. Jour. Australia, I: 413, 1923.
Biography. Hygeia, 2: 97, 1923; 5: 59, 1927; 6: 222, 1928.
Biography. Crusader, 14: 18, 1923.
Robert Koch
735
Diary. Biography by F. Kleine. Deutsche med. Woch., 50:
21-24; 55; 88; 121; 152; 184; 216; 248, 1924.
Biography by V. Robinson. Med. Life, New York, 31 : 336-374,
1924.
Biography by M. Kirchner, Vienna, 1924.
Biographical notes bearing on Koch, Ehrlich Behring and
Loffler, with portraits and letters from three of them. By
G. H. F. Nuttall. Parasitology, 16: 214-238, 1924-1925.
Koch, the death fighter. By P. de Kruif. In Microbe Hunters,
New York, Harcourt, Brace and Co., 1926. Ch. 5, pp. 105-
1 44 -
Biography by I. Goldston. Med. Life, 33: 589-591, 1926.
Fiftieth anniversary of his first work. By A. Walter. Ref. de
med., Rosario, 2: 41-44, 1927.
Letters. (Briefe aus vergangenen Tagen.) Deutsche med.
Woch., 55: 1772, 1929.
Biography by E. E. Meyer. Valencia, Mora, 1929. 24 pp.
25.5 cm. Also, repr.: Revista Lig. tuber., pp. 255-256,
July-August, 1929.
Medizin und Philosophie. Miinchen. med. Woch., 76: 10-13,
1929.
Twentieth anniversary of death. By M. Hahn. Med. Klin.
26: 796, 1930.
Biography by M. Miyajima. Geneva, “Sonor”, 1931. 99 pp.
port., 17.5 cm.
Biography. New England Jour. Med., 204: 942-944, 1931.
Biography by J. Alvarez Sierra. Dia. med., 3: 5 ^ 7 > I 93 I *
High lights in the life of Robert Koch. By H. Subin. Jour.
Med. Soc. New Jersey, 28: 342-343, 1931.
Memorial volume in honor of fiftieth anniversary of discovery of
tubercle bacillus. Med. Klin., 28: 387-424, 1932.
Effect of discovery of tubercle bacillus on hygiene. By P. Uhlen-
huth. Ibid., 387-393, 1932.
Effect of discovery of tubercle bacillus on pathologic anatomy of
tuberculosis. By L. Aschoff. Ibid., 394 _ 395 > x 93 2 *
Fiftieth anniversary of discovery of tubercle bacillus. By T.
Brugsch. Ibid., 395~39 s > 1 93 ' 1 -
Medical Classics
73 6
Effect of discovery of tubercle bacillus on pediatrics. By H.
Kleinschmidt. Ibid., 398-400, 1932.
Effect of discovery of tubercle bacillus on gynecology. By M.
Henkel. Ibid., 400-401, 1932.
Effect of discovery of tubercle bacillus on surgery and on surgical
tuberculosis. By O. Stahl. Ibid., 402-403, 1932.
Influence of discovery of tubercle bacillus on otorhinolaryngology.
By A. Briiggemann. Ibid., 404-405, 1932.
Discovery of tubercle bacillus in relation to dermatology. By
J. Jadassohn. Ibid., 406-407, 1932.
Announcement of discovery of tubercle bacillus before Congress
on Internal Medicine in Wiesbaden, in 1882. Ibid., 420-
423, 1932.
Memorial volume in honor of fiftieth anniversary of discovery of
tubercle bacillus. Med. Welt, 6: 325-364, 1932.
In memory of March 24, 1882, day on which Robert Koch an-
nounced his discovery of tubercle bacillus. By R. Pfeif-
fer. Ibid., 325-327, 193a.
In memory of fiftieth anniversary of day on which Robert Koch
announced his discovery of tubercle bacillus. By W. Kolle.
Ibid., 328-332, 1932.
Fifty years since discovery of tubercle bacillus. By R. Otto.
Ibid., 333-334, 1932.
Koch and development of communal hygiene. By Von Drigalski.
Ibid., 348-3 5°> 1 932-
Work in federal health department. By L. Haendel. Ibid.,
35 I_ 353> 1932.
Koch and laws for prevention of communicable diseases. By
O. Lentz. Ibid., 354-356, 1932.
Expeditions for study of relapsing fever in 1905 and trypano-
somiasis in 1906. By R. Kudicke. Ibid., 359-362, 1932.
Personal reminiscences. By C. Benda. Ibid., 362-363, 1932.
Life and work. By J. Martens. Ibid., 363-364, 1932.
Memorial volume in honor of fiftieth anniversary of discovery of
tubercle bacillus. Zeits. f. Tuberk. 64: 1-126, 1932.
Influence of discovery of tubercle bacillus on clinical knowledge
of tuberculosis. By A. Goldscheider. Ibid., 476-478, 1932.
Robert Koch
737
Effect of discovery on pathologic morphology and general pa-
thology of tuberculosis. ByLubarsch. Ibid., 478-481, 1932.
Influence of Koch’s discovery and teachings on surgery. By E.
Payr. Ibid., 481-487, 1932.
Life work in its effect on public welfare. By C. Hamel. Ibid.,
487-488, 193a.
Influence on Prussian Board of Health. By Schopohl. Ibid.,
489-49°, 1932.
Effect of discovery on knowledge of immunity. By R. Pfeiffer.
Ibid., 490-493, 1932.
Importance of discovery of tubercle bacillus in therapy and pro-
phylaxis of infectious diseases. By W. Kolle. Ibid.,
493"495> J 93 2 -
Koch’s discovery in relation to clinical aspects of infectious dis-
eases. By U. Friedemann. Ibid., 495-497, 1932.
Work in field of tuberculosis. By F. Neufeld. Ibid., 497-499,
. . I932 \
Clinical significance of discovery of tubercle bacillus. By E.
von Romberg. Ibid., 64: 3-6, 1932.
Robert Koch. By F. Sauerbruch. Ibid., 7-9, 1932.
Results of discovery of tubercle bacillus. By R. Philip. Ibid.,
9 -j6, 1932.
Significance of discovery of tubercle bacillus for pathologic anat-
omy. By P. Huebschmann. Ibid., 17-23, 1932.
Work in relation to modern experimental research on tuberculosis.
By B. Lange. Ibid., 31-38, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. By A.
Calmette. Ibid., 239-245, 1932. Also: Bull. Acad, de
med., Paris, 107: 346-355, 1932. Also: Presse med., 40:
387-389, J 93 2 *
Robert Koch and combat of tuberculosis; fiftieth anniversary
of discovery of tubercle bacillus. By F. A. Weber. Ztschr.
f. Tuberk., 64: 399-415, 1932.
Robert Koch-Ehrung. Deutsche med. Woch., 58: 423 only,
1932.
Memorial volume in honor of fiftieth anniversary of discovery of
tubercle bacillus. Ibid., 475-518, 1932.
Medical Classics
Contribution to experimental research on tropical diseases. By
F. K. Kleine. Ibid., 505-508, 1932.
Robert Koch and England. By W. Bulloch. Ibid., 508-509,
1 93 2 -
Robert Koch and Japan. By M. Miyajima. Ibid., 509-510,
. I 93 2 -
Fiftieth anniversary of discovery of causative agent of tuberculo-
sis. By R. Pfeiffer. Forsch. u. Fortschr., 8: 113-115, 1932.
Problem of tuberculosis in 1882 and in 1932; account of fiftieth
anniversary of discovery of tubercle bacillus; historical note.
By S. Sterling. Polska gaz. lek., 11 : 213-217, 1932.
Significance of discovery of tubercle bacillus. By E. Zimmer-
mann. Zeits. f. Med.-Beamte, 45: 93-107, 1932.
Koch and tuberculin therapy. By W. Neumann. Wien. med.
Woch., 82: 407-408, 1932.
Work in hygiene. By E. Glaser. Ibid., 435-438, 1932.
What Koch meant to tuberculosis. By L. Brown. Libman An-
niv. Vols., 1: 253-264, 1932.
Work of Koch as basis for recent developments in clinical study of
tuberculosis. By M. R. Borok. Sovet. vrach. gaz., pp.
901-906, 1932.
Koch and his conception of problem of tuberculosis. By E. E.
Ben and M. L. Goldfarb. Ibid., pp. 1248-1252.
Biography by Gnant. Med. Kor.-Bl. f. Wiirttemberg, 102:
192-196, 1932.
Life work: in memory of fiftieth anniversary of discovery of
tubercle bacillus. By R. Hilgermann. Zeits. f. Gesundh.,
24: 105-108,1932. Also: Prakt. Desinf., 24: 131-136, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. Zeits.
f. Hyg. u. Infekt., 113, Hft. 4, 1932.
Reminiscences of African expedition. By F. K. Kleine. Fort-
schr. d. Med., 50: 959-966, 1932.
Discovery of etiology of tuberculosis. By O. Roepke. Zeits.
f. Bahnarzte, 27: 59-69, 1932.
Biography by W. Kolle. Zentralbl. f. Bakt., 127: 3-10, 1932.
Speech on fiftieth anniversary of discovery of tubercle bacillus.
By R. Maresch. Wien. klin. Woch., 45: 417-419, 1932.
Robert Koch
739
Address delivered at fiftieth anniversary of discovery of tubercle
bacillus. By N. Jagic. Ibid., 419-421, 193a.
Fiftieth anniversary of discovery of tubercle bacillus. By F,
Hamburger. Ibid., 421-422, 1932.
Value of discovery of tubercle bacillus to medical science. By
J. L. A. Peutz. Geneesk. gids., 10: 295-303, 1932.
Discovery of tubercle bacillus. By A. de Besche. Nord. med.
tidskr., 4: 1 93-195, 1932.
Biography by G. Schroder. Tuberkulose, 12: 45-47, 1932.
Biography by Bruno Heymann. Leipzig, 1932. 353 pp.
Discovery of tubercle bacillus. By D. Okolicsanyi-Kuthy.
Budapesti orvosi ujsag., 30: 481-483, 1932.
The role of Robert Koch in combating tuberculosis. By J.
Geszti. Ibid., 553-558, 1932.
Announcement of discovery of tubercle bacillus. By H. Unger.
Zeits. f. arztl. Fortbild., 29: 189-191, 1932.
In memoriam. By F. A. Weber. Ibid., 404-409, 1932.
Discovery of tubercle bacillus. By O. von Hellens. Finska
lak.-sallsk. handl., 74: 1 25-1 27, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. By A.
Ferrannini. Riforma med., 48: 413-415, 1932.
Work of Italian Clinical schools in application of Koch’s dis-
covery of tubercle bacillus. By N. Pende. Ibid., 1901-
1902, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. By A.
Filippini. Policlinico (sez. prat.) 39: 581-582, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. By R.
Hernandez del Castillo. Med. ibera, 1: cxlix-cli, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. By B.
Heymann. Klin. Woch., 11: 489-490, 1932.
Biography by Z. Szymanowski. Warszawskie czasop. lek.,
9 : 271-273, 1932.
Personal memories. By O. Bujwid. Ibid., 9: 273-275, 1932.
Discovery of tuberculin. By Z. Srebrny. Ibid., 275-278, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. By K.
Kisskalt. Miinchen. med. Woch., 79: 497 "' 5 OI > ! 93 2 -
Description of Koch celebration in Berlin, March 5, 1932.
Veroffentl. a. d. Geg. d. Med.-Verwalt., 37: 1-50, 1932.
Medical Classics
740
Discovery of anthrax spores and tubercle bacilli. By G. Venz-
mer. Mikrokosmos, 26: 5; 29, 1932.
In memory of the great scientist and his importance in medicine.
By W. Kolle. Arb. a. d. Staatsinst. f. exper. Therap.,' Hft.
26, pp. 1-10, 1932.
Active campaign against tuberculosis in Russia in connection with
observance of Koch jubilee. By S. E. Nezlin. Bor. s
tuberk., 10: 525-527, 1932.
Life and significance of Robert Koch in microbiology and epi-
demiology. By V. A. Lyubarskiy. Bor. s. tuberk., 10:
537-544, I 93 a -
Evolution of study of tubercle bacillus from time of Koch to
present day. By O. I. Bronshteyn. Ibid., 544-553, I 93 2 -
Fiftieth anniversary of discovery of tubercle bacillus. By L.
'Pekanovich. Orvosi hetil., 76: 263, 1932.
Discovery of tubercle bacillus by Robert Koch. Tijdschr. v.
sociale hyg., 34: 138-140, 1932.
Contributions of Koch to knowledge of tuberculosis. By A.
Ilvento. Lotta contro la tuberc., 3: 828-832, 1932.
Present status of clinical concept of pulmonary tuberculosis at
fiftieth anniversary of discovery of tubercle bacillus, with
biographical sketch of Koch. By R. Royo Villanova. Clin.
. J lab -’ 21 : 365—386, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. By F. K.
Kleine. Rev. med. german.-ibero-am., 5: 113-115, 1932.
Life. By P. Farreras. Rev. espan. de med. y cir., 15: 119-121,
1932 ‘
Robert Koch and his discoveries in tuberculosis. By A. Cervero
Lacort. Mundo med., 14: 760-768, 1932.
In memoriam. By A. Raimondi. Rev. Asoc. med. argent., 46:
419-421, 1932.
In memoriam. By A. Bachmann. Ibid., 421-428, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. By F.
Buonomo La Rossa. Rassegna internaz. di clin. e terap.,
*3 : 3 28 73 2 9, J 93 2 -
Fiftieth anniversary of discovery of tubercle bacillus. By S.
Coelho. Med. contemp., 50: 169-173, 1932.
Robert Koch 74.1
Fiftieth anniversary of discovery of tubercle bacillus. By J.
Torres Gost. Rev. espan. de tuberc., 3: 209-221, 1932.
Fiftieth anniversary of discovery of tubercle bacillus: bio-
graphical sketch of Koch. By A. Pruneda. Gac. med. de
Mexico, 63: 268-273, 1932. Also: Rev. med. german.-
ibero-am., 5: 497-501, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. By F.
deP. Miranda. Salubridad, 3: 225-227, 1932.
En memoria — por Codina Castellvi, Jose. Anales Acad. nac.
med. 1932, 2 epoca, tomo 4, cuaderno 2, 2 trimestre, p.
251-268, 1932.
Discovery of tubercle bacillus. By L. Bernard. Rev. de la
tuberc., 13: 506-509, 1932.
Fiftieth anniversary of discovery of tubercle bacillus; thoughts in
honor of Koch’s genius. By Martin Salazar. Rev. san.
mil., Madrid, 22: 97-99, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. By M.
Lelong. Paris med. (annexe), I: x-xi, 1932.
Fiftieth anniversary of discovery of tubercle bacillus. By A.
Vadone. Prensa med. argent., 18: 1377-13795 1932.
Discovery of tubercle bacillus on Mar. 24, 1882. By F. K.
Kleine. Tung-Chi. med. Monatschr., 8: 47-49, 1932.
Discovery of tubercle bacillus by Robert Koch. By V. Puntoni.
Ann. d’ig., 42: 168-170, 1932.
Influence of discovery of tubercle bacillus on medicine. By R.
A. Young. Tr. Nat. Assn. Prev. Tuberc., 18: 11-20, 1932.
Influence of discovery of tubercle bacillus on preventive medicine.
By W. C. White. Ibid., 21-28, 1932.
Influence of Koch’s discovery on surgery, with particular refer-
ence to treatment of surgical tuberculosis. By H. Gauvain.
Ibid., 29-43, 1932.
Koch anniversary, the man and his work. By D. A. Stewart.
Canad. Med. Assn. Jour., 26: 475-478, 1932.
H. M. Biggs lecture. By L. Brown. Bull. New York Acad.
Med., 8: 558-584, 1932.
Robert Koch and his work. By C. M. Hasselmann. Jour.
Philippine Islands Med. Assn., 12: 328-335, 1932.
Medical Classics
74 2
Robert Koch number. Med. Life, 39: 129-187, 1932-
Biography by G. B. Webb. Nat. Tuberc. Assn. Tr., 28: 24-38,
1932. Also: Ann. Med. Hist., 4: 509-523, 1932.
Koch’s views on stability of species among bacteria. By T.
Smith. Ibid., 524-530, 1932.
Reception of Koch’s discovery in United States. By H. R. M.
Landis. Ibid., 531-537, 1932.
Discovery of tubercle bacillus. By A. K. Krause. Amer. Rev.
Tuberc., 25: 285-298, 1932.
Professor Robert Koch in Iowa in 1908. Jour. Iowa Med. Soc.,
22: 153-154, 1932.
Pioneers in medicine. By C. Lillingston. Hygeia, 10: 248-
250, 1932.
Koch and golden anniversary of discovery of tubercle bacillus.
By S. A. Knopf. Med. Jour, and Rec., 135: 305-308,
1932.
Koch and tuberculosis. By K. Emerson. Journal-Lancet,
52: 215-216, 1932.
In memoriam; fiftieth birthday of tubercle bacillus. By F.
Baum. Jour. Med. Soc. New Jersey, 29: 238-243, 1932.
Discovery of tubercle bacillus. By S. L. Cummins. Brit. Jour.
Tuberc., 26: 72-75, 1932.
Biography. Med. Rec., 79: 76, 1932.
Discovery by Koch. By L. Cobbett. Cambridge Univ. Med.
Soc. Mag., 9: 93-102, 1932.
Biography by S. A. Knopf. Unity, Kansas City, April 11, 1932,
pp. 90-91.
Biography by H. J. Corper. Colorado Med., 29: 353-362, 1932.
Biography by Grace T. Hallock and C. E. Turner, Metropolitan
Life Ins. Co. Health Heroes, 1932.
What Koch meant to tuberculosis. By Lawrason Brown. In:
Contributions to Med. Sc. in Honor of D. E. Libman, New
York, International Press, 1932. Vol. 1, p. 253-264.
Discovery of tubercle bacillus; implications and results. By R.
Philip. Brit. Med. Jour., 2: 1-5, 1932. Also: Amer. Rev.
Tuberc., 26: 637-652, 1932.
Robert Koch
743
Discovery of tubercle bacillus; importance and significance. By
Y. G. Shrikhande. Indian Med. Gaz., 67: 691-692, 1932.
Discovery of the tubercle bacillus. By Helen C. Davis. Science
News Letter, March 19, 1932.
Discovery of cholera bacillus by Koch 50 years ago. By Frey.
Klin. Woch., 12: 1376-1379, 1933.
Koch’s discovery of cholera vibrio. By F. K. Kleine. Zeits.
f. arztl. Fortbild., 30: 385-386, 1933.
Koch and problem of tuberculosis; fiftieth anniversary of dis-
covery of tubercle bacillus. By M. Nasvytis. Medicina,
Kaunas, 14: 4-13, 1933.
The tubercle bacillus since Koch’s discovery. By S. A. Petroff.
Bol. Asoc. med. de Puerto Rico, 25: 167-175, 1933.
Biography by E. Metchnikoff. Paris, Alcan, 1933. xi, 195 pp.,
18.5 cm.
Discovery of tubercle bacillus; implications and results. By R.
Philip. Edinburgh Med. Jour., 40: 146-157, 1933.
Biographical sketch by H. E. Sigerist. In The Great Doctors,
New York, Norton, 1933. Ch. 43, pp. 366-372.
Biography by R. Munoz Carbonero. Cron, med., Valencia, 38:
613-616, 1934.
First criticism of Robert Koch by followers of Pettenkofer. By
K. Kisskalt. Arch. f. Hyg., 112: 167-180, 1934.
Fifty years after discovery of tubercle bacillus; present status
of study of tubercle bacilli and tuberculin. By H. Poin-
decker. Wien, med. Woch., 84: 151; 178, 1934.
Biography by A. Leber. Geneesk. tijdschr. v. Nederl. — Indie,
75: 1030-1034, 1935.
Biography by P. Martell. Zeits. f. arztl. Fortbild., 32: 332-335,
I 935* .
Author’s remembrances of Koch on twenty-fifth anniversary of
his death. By B. Mollers. Rev. med. german. — ibero —
am., 8: 161-163, 1935.
Unveiling of bust in Hall of Fame of German Museum in Mun-
ich. By C. Schilling. Deutsche med. Woch., 61 : 851, 1935.
Koch’s work. By R. Otto. Med. Klin., 31: 669-671, 1935-
Medical Classics
744
Koch and landmarks in history of medicine. By D. P. Marais.
South African Med. Jour., 9: 659-663, 1935.
American tribute. By L. Brown. Ann. Med. Hist., 7: 99-1 12;
292-304; 385-401, 1935.
Biography. Amer. Jour. Surg., 27: 376, 1935.
Koch, a singularly great doctor of medicine. By A. Beilin.
Hygeia, 13: 507, 1935. .
Biographical sketch by C. Lillingston. Ibid., March 1935*
Note on the Koch memorial. Jour. Amer. Med. Ass., 105:
44 8 , I 935-
Sketch by G. B. Webb. In Tuberculosis, vol. 16 of Clio Medica.
New York, Hoeber, 1936. pp. 96-107.
Untersuchungen iiber Bacterien
V. Die Aetiologie der Milzbrand-Krankheit, begriindet
auf die Entwicklungsgeschichte des
Bacillus Anthracis
VON
DR. KOCH
Kreisphysikus in IVollsttin
Hierzu Tafel XI.
Bcitragc zur Biologic der Pilanzen, 2 : 277-310, 1877
INLEITUNG. Seit dem Auffinden der stab-
chenformigen Korper im Blute der an Milzbrand
gestorbenen Thiere hat man sich vielfach Muhe
gegeben, dieselben als die Ursache fur die direkte
Uebertragbarkeit dieser Krankheit ebenso wie
fur das sporadische Auftreten derselben, also
als das eigendiche Contagium des Milzbrands nachzuweisen.
In neuerer Zeit hatte sich hauptsachlich Davaine mit dieser
Aufgabe beschaftigt und gestiitzt auf zahlreiche Impfversuche
mit frischem oder getrocknetem stabchenhaltigen Blute, mit
aller Entschiedenheit dahin ausgesprochen, dass die Stabchen
Bacterien seien und nur beim Vorhandensein dieser Bacterien
das Milzbrandblut die Krankheit von Neuem zu erzeugen ver-
moge. Die ohne nachweisbare direkte Uebertragung entstand-
cnen Milzbranderkrankungen bei Menschen und Thieren fuhrte
cr au f die Verschleppung der, wie er entdeckt hatte, im getrock-
ncten Zustande lange Zeit lebensfahig bleibenden Bacterien
durch Luftstromungen, Insekten und dergl. zuruck. Die ^'er-
746 Medical Classics
breitungsweise des Milzbrandes schien hiermit vollstandig klar
gelegt zu sein.
Dennoch fanden diese von Davaine aufgestellten Satze von
verschiedenen Seiten Widerspruch. Einige Forscher wollten
nach Impfung mit bacterienhaltigem Blute todlichen Milzbrand
erzielt (p. 278) haben, ohne dass sich nachher Bacterien im
Blute fanden, und umgekehrt Hess sich wieder durch Impfung
mit diesem bacterienfreien Blute Milzbrand hervorrufen, bei
welchem Bacterien im Blute vorhanden waren. Andere machten
darauf aufmerksam, dass der Milzbrand nicht allein von einem
Contagium abhange, welches oberhalb der Erde verbreitet werde,
sondem dass diese Krankheit in einem unzweifelhaften Zusam-
menhange mit Bodenverhaltnissen stehe. Wie wiirde sonst zu
erklaren sein, dass das endemische Vorkommen des Milzbrandes
an feuchten Boden, also namentlich an Flussthaler, Sumpf-
distrikte, Umgebungen von Seen gebunden ist; dass ferner die
Zahl der Milzbrandfalle in nassen Jahren bedeu tender ist und
sich hauptsachlich auf die Monate August und September, in
welchen die Curve der Bodenwarme ihren Gipfelpunkt erreicht,
zusammendrangt, dass in den Milzbranddistricten, sobald die
Heerden an bestimmte Weiden und Tranken gefuhrt werden,
jedesmal eine grossere Anzahl von Erkrankungen unter den
Thieren eintritt.
Diese Verhaltnisse sind allerdings durch die Annahme Da-
vaine’s nicht zu erklaren und das Ungeniigende derselben hat
zur Folge gehabt, dass von Vielen die Bedeutung der Bacterien
fur den Milzbrand ganz geleugneit ist.
Da ich einige Male Gelegenheit hatte, Thiere, welche an Milz-
brand gefallen waren, zu untersuchen, so benutzte ich diese zu
einer Reihe von Versuchen, welche zur Aufklarung der eben
angedeuteten dunklen Punkte in der Milzbrandatiologie bei-
tragen sollten. Hierbei kam ich sehr bald zu der Ueberzeugung,
dass die Davaine’sche Theorie uber die Verbreitungsweise des
Milzbrandes nur zum Theil richtig ist.
Es zeigte sich namlich, dass die Stabchen des Milzbrandblutes
die Weitem nicht so resistent sind, als Davaine seinen Versuchen
entnehmen zu mussen glaubte. Wie ich spater nachweisen
Untersuchungen iiber Bacterien 747
werde, bewahrt das Blut, welches nur Stabchen enthalt, seine
Impffahigkeit im getrockneten Zustande nur wenige Wochen
und im feuchten nur einige Tage. Wie sollten also so leicht
vergangliche Organismen das oft wahrend des ganzen Winters
und im feuchten Boden vielleicht Jahrelang schlummernde Con-
tagium des Milzbrandes bilden? Hier blieb, wenn die Bacterien
wirklich die Ursache des Milzbrandes abgeben, nichts anderes
iibrig als anzunehmen, dass die durch einen Generationswechsel
in einen anderen gegen abwechselndes Eintrocknen und An-
feuchten unempfindlichen Zustand iibergehen konnen, oder, was
weit mehr Wahrscheinlichkeit hat und was von Prof. Cohn
schon im zweiten Hefte, Band I. dieser Beitrage p. 145, ange-
deutetwurde, (p. 279) dass die Bacterien Sporen bilden, welche
die Fahigkeit besitzen, nach langerem oder kiirzerem Ruhezu-
stande von Neuem zu Bacterien auszuwachsen.
Alle meine weiteren Versuche gingen nun dahin, diesen ver-
mutheten Entwicklungszustand der Milzbrandbacterien aufzu-
finden. Nach manchen vergeblichen Bemuhungen gelang es
denn auch schliesslich dieses Ziel zu erreichen und damit die
vahre Milzbrandatiologie in ihren Grundziigen festzustellen.
Da die Entwicklungsgeschichte der Milzbrandbacterien nicht
nur botanisches Interesse bietet, sondern auch manches Licht
auf die bis jetzt so dunkle Aetiologie der vom Boden abhangigen
Infectionskrankheiten zu werfen im Stande ist, so habe ich es
jetzt schon, obwohl meine Versuche noch nicht abgeschlossen
sind, unternommen, die wichtigsten Resultate derselben zu
veroffentlichen.
II. Entwicklungsgeschichte des Bacillus Anthracis. Die Milz-
brandbacterien gehoren nach Prof. F. Cohn’s System der Schizo-
pliytcn* zur Gattung Bacillus und sind mit dem speciellen Namen
Bacillus Anthracis belegt, dessen ich mich im Folgenden statt des
viel umfassenden Ausdrucks Bacterien bedienen werde.
I. Im Blute und in den Gewebssaften des lebenden Thieres
vcrmehren sich die Bacillen ausserordentlich schnell in derselben
^ cisc, wie es bei verschiedenen andern Arten Bacterien beo-
* B:nd I. Heft 3 dieser Beitrage p.
74-8 Medical Classics
bachtet ist, namlich durch Verlangerung und fortwahrende
Quertheilung.
Es ist mir allerdings nicht gelungen, diesen Vorgang direct zu
sehen; derselbe lasst sich aber aus den schon haufig vorgenom-
menen und von mir in folgender Weise wiederholten Impfver-
suchen schliessen. Als sehr bequemes und leicht zu habendes
Impfobjekt benutzte ich meistens Mause. Anfangs impfte ich
dieselben an den Ohren oder in der Mitte des Schwanzes, fand
aber diese Methode unsicher, da die Thiere durch Reiben und
Lecken das Impfimaterial entfernen Konnen; spater wahlte ich
als Impfstelle den Rucken der Schwanzwurzel, wo die Haut schon
verschiebbar und mit langen Haaren bedeckt ist. Die in einem
verdeckten grossen Glase sitzende Maus wird zu diesem Zwecke
mit einer langen Pincette am Schwanze gefasst und letzterer aus
einer schmalen Spake zwischen Deckel und Glasrand so weit
hervorgezogen, dass bequem ein flacher querverlaufender Ein-
schnitt in die Haut des Schwanzwurzelriickens gemacht und ein
moglichst kleines Tropfchen der bacillenhaltigen Flussigkeit (p.
280) in die kleine Wunde gebracht werden kann. In dieser Weise
ausgefuhrte Impfungen, welche ich in grosser Zahl gemacht habe,
hatten ausnahmslos ein positives Resultat, sobald ganz frische
Milzbrand-Substanzen angewandt wurden; und ich glaube des-
wegen eine derartige Impfung, je nach ihrem Erfolgj als ein
sicheres Reagens auf das Leben oder Abgestorbensein der Bacillen
ansehen zu Konnen: eine Ansicht, welche durch andere, spater
zu erwahnende Versuche als richtig erwiesen wird.
Theils nun, um immer mit frischem Material versehen zu sein,
theils aber auch um zu prufen, ob nicht nach einer bestimmten
Zahl von Generationen die Bacillen in eine andere Form iiber-
gehen, wurden mehrere Male Mause in aufeinanderfolgender
Reihe geimpft, so dass ohne Unterbrechung die folgende Maus
immer mit der Milzsubstanz der kurz vorher an Milzbrand
gestorbenen inficirt wurde. Die langste dieser Reihen betrug
zwanzig Mause, so dass also eben so viele Bacillengenerationen
vorlagen; aber bei sammtlichen Thieren ergab sich derselbe Be-
hind; immer war die Milz erheblich geschwollen und mit zahllosen
Mengen von glashellen Stabchen gefiiillt, welche geringe Grossen-
differenzen hatten, unbeweglich waren und keine Sporenbildung
Untersuchungen iiber Bacterien 749
oder dergleichen zeigten. Dieselben Bacillen fanden sich auch,
aber bei weitem nicht so zahlreich als in der Milz, im Blute. Bei
diesem Versuche hatten sich also durch vieie Generationen ails
wenigen Bacillen immer wieder bedeutende Massen ebenso
gestalteter Individuen derselben Art entwickelt und da man
unter diesen neu entstandenen Bacillen vieie mit einer beginnen-
den Quertheilung in ihrer Mitte, manche an dieser Stelle gek-
nickte und noch andere unter einem Winkel lose zusammen-
hangende erblickt, so lasst sich wohl eine andere Weise ihrer
Vermchrung als durch Verlangerung und Quertheilung, nachdem
sie ungehahr die doppelte Lange erreicht haben, kaum annehmen.
Es diirfte aber auch nach diesem Resultat schwerlich zu erwarten
sein, dass durch noch langere Reihen von Impfungen eine Form-
veranderung der Bacillen erreicht werden, oder dass man sehlies-
slich auf einen Generationswechsel derselben treffen konnte.
Auch in dem der Impfstelle benachbarten seros infiltrirten Unter-
hautzellgewebe und in den nachsten Lymphdriisen fand ich bei
Kaninchen und Meerschweinchen nur kurze und in der Thcilung
begriffene Stabchen.
Die Vertheilung der Bacillen im Korper der geimpften Thicrc
ist nicht immer gleichmassig. Bei Meerschweinchen cnthielt
das Blut ausserordentlich vieie Bacillen, so dass inre Zahl oft
dcrjenigen der rothen Blutkorper gleichkam oder sie selbst
ubertraf; im Blute (p. 281) der Kaninchen sind sie erheblich
weniger zahlreich, oft so selten, dass man mehrere Gesichtsfelder
durchmustern muss, ehe man einige findet;,bei Mausen enthalt
das Blut stets eine so geringe Zahl Bacillen, dass sie manchmal
zu fehlen scheinen.* Dafiir findet man bei Kaninchen die
Bacillen um so reichlicher und sicherer in den Lymphdruscn und
in der Milz, und bei Mausen in erstaunlicher Menge in der Milz.
Einigemale habe ich die Marksubstanz der Tibia von Mausen
untcrsucht, aber nur vereinzelte Bacillen darin gefunden.
Auf weitere hierher gehorige Details fiber die Lagerung der
Bacillen im Gewebe der Milz, in den Blutgefassen, fiber ihrc
* Dsrsrtigc Fallc habtn wahrscheinlich, vrcr.n nur das Blut der rr. it Milzbr
Thitre untcrsucht w*urdc, zur fruher erwahnten Ar.sicnt gtfuhrt, czss
f BacIIcn im Blute sich finden, vorkomme ur.a dsss man ccrch Ij
h : c;!cnfre :cm Blute wieder MU zb rand erzeugen konr.e.
7^0 Medical Classics
Anhaufungen in den Capillaren und kleinen Venen und die
dadurch bedingten lokalen Oedeme, Gefasszerreissungen und
Blutaustritte vermag ich wegen des rein pathologischen Interesses
dieser Ver haltnisse hier nicht weiter einzugehen.
Ebenso wurde es zu weit fuhren, die Frage nach der eigent-
lichen Todesursache der an Milzbrand sterbenden Thiere zu
erortern, ob dieselben durch die bei dem intensiven Wachsthum
der Bacillen im Blute entwickelte Kohlensaure oder, was wohl
wahrscheinlicher ist, durch giftig wirkende Spaltprodukte der
von den Parasiten zu ihrer Ernahrung verbrauchten Eiweiss-
korper getodtet werden.
i. Im Blute des todten Thieres odern in geeigneten andern
Nahrflussigkeiten wachsen die bacillen innerhalb gewisser Tem-
peraturgrenzen und bei Luftzutritt zu ausserordentlich langen,
unverzweigten Leptothrix - ahnlichen Faden aus, unter Bildung
zahlreicher Sporen.
Am einfachsten iiberzeugt man sich von der Richtigkeit dieses
Satzes durch folgendes Experiment:
Auf den Objecttrager wird ein Tropfen von moglichst frischem
Rinderblutserum oder Humor aqueus von Rinderaugen gebracht,
in diesen ein ldeines Stiickchen frische bacillenhaltige Milzsub-
stanz eingetragen und das Deckglaschen so darauf gelegt, dass
die Baciilenmasse ungefahr in die Mitte des Praparats zu liegen
kommt. Hierauf wird der Oejecttrager, um die Verdunstung
der Flussigkeit zu verhuten, sofort in einen feuchten Raum
gebracht und mit diesem in den Briitkasten gestellt.*
* Als feuchten Raum benutzte ich fiache mit nassem Sand gefullte Teller; auf dem
Sand lag eine Schicht Filtrirpapier und auf diesem die Praparate. Der Teller wurde
mit einer Glasplatte bedeckt. Wenn die Sandschicht so hoch ist^ dass der Abstand
zwischen der Oberfiache der Praparate und der unteren Seite der Glasplatte ^ bis X Ctm.
betragt, dann bleiben die Praparate genugend feucht. Der von mir angewandte Brut-
apparat, welcher sechs auf einander gestellte Teller mit Praparaten aufnehmen konnte,
v-airde in Ermangelung von Gas durch eine mit Cylinder versehene Petroleumlampe
erwarmt. Allen, welche ohne Gas oder ohne Regulator derartige Versuche mit dem
Brutapparat unternehmen wollen, kann ich diese Methode der Heizung nicht genug
empfehlen. Da man mit einer kleinen Flamme einen grossen Apparat genugend er-
warmen kann, so ist bei einem einigermassen grossen Petroleumreservoir der Lampe nur
nothig, dieselbe ungefahr taglich einmal zu fullen und die Hohe der Flamme fur die
gewunschte Temperatur richtig auszuprobiren, um ohne besondere Muhe oder Aufsicht
fortwahrend eine kaum um schwankende Temperatur zu haben.
Untersuchungen iiber Bacterien 751
(p. 282) Der Wassergehalt der Luft in dem feuchten Raum
muss so regulirt werden, dass die Fliissigkeit nicht unter dem
Deckglase hervordringt und dass das Serum am Rande des Deck-
glases nicht eintrocknet. Im ersteren Falle werden die Bacillen
unter dem Deckglaschen weggeschwemmt und entgehen der
Beobachtung, im letzteren wird durch die trockne Randschicht
des Serums die Luft von den Bacillen abgesperrt und jede weitere
Entwickelung derselben damit verhindert.
Die so zubereiteten Praparate bleiben 15-20 Stunden im Briit-
apparat bei einer Temperatur von 35— 37 0 . Bei einer alsdann
vorgenommenen Untersuchung finden sich in der Mitte des
Praparats (Taf. XI. Fig. 1) zwischen den noch gut erhaltenen
Zellen der Milzpulpa und den Blutkorperchen (a, b) noch viele
unveranderte Bacillen, jedoch in geringerer Zahl als im frischem
Praparate. Sobald man aber die Mitte des Praparates verlasst,
trifft man auf Bacillen, welche um das 3-8 fache verlangert sind
und dabei einige leichte Knickungen und Kriimmungen zeigen
(Fig. 2). Je naher man nun dem Rande des Deckglases kommt,
um so langere Faden findet man, welche vielfach gewunden sind
und schliesslich die hundert- und mehrfache Lange der urspriing-
lichen Bacillen erreichen (Fig. 3). Viele dieser langen Faden
haben ihre gleichmassige Struktur und ihr glashelles Aussehen
verloren, ihr Inhalt ist fein granulirt und stellenweis treten in
demselben kleine starker lichtbrechende Kornchen in regelmas-
sigen Abstanden auf (Fig. 3a). In den dicht am Rande befind-
lichen Faden, welche also in Bezug auf den Gasaustausch in der
Nahrflussigkeit am giinstigsten liegen, ist die Entwickelung am
weitesten vorgeschritten; sie enthalten vollstandig ausgebildete
Sporen, welche in der Gestalt von etwas langlich runden, (p. 283)
stark lichtbrechenden Korpern in ganz regelmassigen kurzen
Abstanden der Substanz der Faden eingelagert sind (Fig. 4a). In
dieser Form gewahren die Faden, namentlich wenn sie in vielfach
verschlungenen und um einander gewundenen Linien gruppirt
sind, einen iiberraschenden Anblick, der sich am besten mit
demjenigen hochst zierlicher, kunstlich angeordneter Perlschniire
vergleichen lasst.
Manche Faden sind auch schon in der Auflosung begriffen und
Medical Classics
75 2
ihre fruhere Gestalt nur noch durch die reihenformige Lagerung
der von einer schleimigen Bindesubstanz zusammen gehaltenen
Sporen angedeutet. Dazwischen liegen dann bisweilen einzelne
freie und kleine Haufchen zusammen geballter Sporen (Fig. 4b).
In einem einzigen solchen gut gelungenen Praparate sind also alle
Uebergange von dem kurzen Bacillusstabchen bis zu langen
sporenhaltigen Faden und freien Sporen vertreten und es konnte
damit schon der Beweis dafiir gebracht sein, dass letztere aus
ersteren hervorgegangen sind. Trotzdem ich anfangs diesen
Versuch mehrfach wiederholte und immer wieder zu demselben
Resultate kam, stiegen mir doch verschiedene Bedenken gegen
die Richtigkeit dieser Annahme auf. Wie kamen die Bacillen,
an denen ich bis dahin keine selbstandige Bewegung wahrgenom-
men hatte, an den Rand des Praparates, wahrend die Blut-
korperchen in der Mitte liegen blieben? Konnten die langen
sporenhaltigen Faden nicht moglicherweise am Rande der Fliis-
sigkeit durch aus der Luft dahin gelangte Keime entstanden sein?
Denn gegen eine derartige Verunreinigung aus der Luft waren die
Praparate nicht geschutzt und in der That wucherten neben den
Faden auf diesem Wege oft die schonsten Colonien von Micrococ-
cus und Bacterium in das Praparat Linein; einigemale erschien
auch eine der unsrigen ahnliche Bacillusart. Hier kam also
Alles darauf an, vollstandige Sicherheit zu erlangen und nicht in
einen Fehler zu verfallen, welcher leider schon so oft bei Cultur-
versuchen mit den niedersten Organismen von erfahrenen For-
schern begangen ist und durch welchen die Untersuchungen auf
diesem Gebiete in neuerer Zeit etwas in Misscredit gekommen
sind. Ich meine den Fehler, ahnliche Formen, welche in der-
selben Nahrfliissigkeit zu gleicher Zeit oder kurz nacheinander
entstanden und zugleich mit scheinbaren Uebergangsformen
vermischt sind, ohne Weiteres als verschiedene Entwickelungs-
stadien desselben Organismus zu erklaren.
Da mir die Bedingungen fur die Entwickelung des Bacillus
Anthracis bekannt waren, namlich die Nahrfliissigkeit, die Tem-
peratur bei welcher er wachst und die Nothwendigkeit der Luft-
zufuhr, so versuchte ich auf dem Mikroskoptisch diese Erforder-
nisse (p. 284) herzustellen, um so direkt die Veranderung der
Bacillen beobachten zu konnen.
Untersuchungen iiber Bacterien 753
So schwierig ich mir anfangs die Ausfiihrung dieses Versuches
vorgestellt hatte, so einfach gestaltete er sich in der Wirklichkeit.
Nach manchem missgliicktem Experiment fand ich folgende
Methode als die Zweckmassigste:
Als Warmequelle diente ein M. Schulze’ scher heizbarer Object-
tisch, welchen ich, ebenso wie friiher vom Briitapparat angegeben
ist, mit einer Petroleumlampe erwarmte. Das Mikroskop muss
allerdings auf einen Untersatz gestellt werden, um die Lampe,
welche mit einem Aachen, aus Blech gearbeiteten Petroleum-
reservoir versehen ist, mit ihrem Cylinder unter den Arm des
heizbaren Objecttisches zu bringen. Eine einzige kleine Flamme,
ungefahr unter der Mitte des einen Arms stehend, genugte bei
meinem Apparat, umtagelang den Objecttisch auf der erforder-
lichen Temperatur zu erhalten. Der feuchte, lufthaltige Raum
wurde von einem durch das Deckglas geschlossenen hohlge-
schliffenen Objecttrager ersetzt (Fig. 6). Das den Bacillen hier-
durch fiir ihre Entwickelung gewahrte Luftquantum ist sehr
gering, aber wie die Erfahrung lehrt, geniigt es zum Gelingen des
Versuches. Um nun die richtige Temperatur fiir die von mir
angewandte Sorte von hohlgeschliffenen Objecttragern zufinden,
benutzte ich den Schmelzpunkt von Rindertalg, welcher im
Wasserbade auf ziemlich genau 40° bestimmt war. Von diesem
vorher gepriiften Rindertalg wurde ein Tropfchen auf ein Deck-
glas gebracht und dieses durch eine rings um die Hohlung des
Objecttragers gepinselte Schicht Provencerol luftdicht, und zwar
mit dem Talgtropfchen nach unten gerichtet, auf den Hohlraum
des Objecttragers aufgesetzt. Es ergab sich dabei, dass der
Objecttisch auf 45° erwarmt werden musste, um den Tropfen
unter dem Deckglase eben zum Schmelzen zu bringen. Fiir die
zu meinen Versuchen erforderliche Temperatur genugte es also,
den Objecttisch so zu heizen, dass sein Thermometer dauernd
auf 40° zeigte. Zu gleicher Zeit musste es auffallen, dass eine
Annaherung des Tubus, wie sie zur Einstellung eines Objectes
fur Hartnack Obj. 7 Ocul. 3, welche ich bei diesen Untersuchungen
benutzte, erforderlich ist, jedesmal stark abkiihlend wirkte und
die Temperatur in dem Tropfen um 5 bis 8° herabsetzte. Nach
diesen Ermittelungen brachte ich auf die untere Seite des Deck-
glases einen Tropfen frisches Rinderblutserum oder, was sich fiir
y54- Medical Classics
diesen Versuch noch viel besser bewahrte, einen Tropfen ganz
frischen und moglichst reinen Humor aqueus von Rinderaugen.
Der Tropfen darf naturlich nur so dick sein, dass (p. 285) man
noch alle seine Schichten mit dem Mikroskop durchmustern
kann.* Hierauf wurde in den Rand des Tropfens eine moglichst
geringe Menge ganz frischer bacillenhaltiger Milzsubstanz
eingetragen und das Deckglaschen sofort auf den mit Oel be-
strichenen Objecttrager gelegt. Der kleine Hohlraum fiillt sich
schnell mit Wasserdampf und die anfangliche Verdunstung des
Tropfens ist so gering, dass nur am aussersten Rand einige Bacil-
len vertrocknen; spater behalt der Tropfen tagelang unverandert
seine Gestalt. Das so hergerichtete Praparat wurde nun auf
den geheizten Objecttisch gebracht und nachdem die Stromungen
in der sich erwarmenden Fliissigkeit sich gelegt flatten, einige
mehr nach dem Innern des Tropfens zu gelegene Bacillen fixirt,
rasch noch ihre Form und Lage gezeichnet und dann der Tubus
hinaufgeschroben, um eine ungleichmassige und zu lange Ab-
kiihlung des Praparates zu vermeiden. Bei der nun folgenden
alle 10 bis 20 Minuten vorgenommenen Untersuchung wurde
wahrgenommen, dass die Bacillen anfangs etwas dicker werden
und anscheinend aufquellen, sich aber in den ersten beiden
Stunden kaum merklich andern. Dann aber beginnt ihr Wach-
sthum. Schon nach 3 bis 4 Stunden haben sie die 10-20 fache
Lange erreicht, sie fangen sich an zu krummen, gegenseitig zu
verdrangen oder geflechtartig durcheinander zu schieben. Nach
einigen weiteren Stunden sind die einzelnen Faden schon so lang,
* Unter verschiedenen Arten hohlgeschliffener Objecttrager fand ich am bequemsten
dnen von 3 Mm. Dicke, vrelcher, beilaufig bemerkt, 60 Mm. lang und 20 Mm. breit ist.
Sdne obere Flache ist matt geschliffen; der Hohlraum hat die Form eines Kugelab-
schnittes, einen Durchmesser von 14 Mm. und eine Tiefe von 1,5 Mm. Hartnack’sche
Deckglaschen von 18 Mm. Quadrat und 0,15 Mm. Dicke lassen sich auf solchen Object-
tragem sehr gut dutch Oel luftdicht befestigen. Dem Tropfen auf der unteren Seite
des Deckglases gab ich einen Durchmesser von ungefahr 5-7 Mm., so dass er vom Oel
ringsum ungefahr noch 3-5 Mm. entfernt bleibt und dieses ihn, selbst wenn es unter
dem Deckglas etwas nach innen flesst, nicht leicht erreichen kann. Zu Kulturver-
suchen im Brutapparat habe ich Objecttrager mit einem darauf befestigten Paraffinring
sehr praktisch gefunden, man kann sich dieselben, in jeder beliebigen Grosse und Form,
leicht selbst anfertigen und ganz in derselben Weise wie hohlgeschliffene Objecttrager
benutzen.
Untersuchungen iiber Bacterien 755
dass sie durch mehrere Gesichtsfelder reichen; sie gleichen einem
Haufen Glasfaden, welche nach Art von Schlingpflanzen sich in
der verschiedensten Weise bald zu langen parallelen Ziigen oder
zu ausserst zierlichen spiralformig gedrehten Biindeln vereinigen,
bald aber in den unregelmassigsten Figuren zu einem unentwirr-
baren Knauel verschlingen, (p. 286) so dass es ganz unmoglich
v/ird, den einzelnen Faden in seiner ganzen Lange weiter zu
verfolgen.
Betrachtet man das freie Ende eines Fadens andauernd durch
langere Zeit, etwa 15 bis 20 Minuten, dann vermag man leicht
die fortwahrende Verlangerung desselben direct wahrzunehmen
und kann sich so das merkwurdige Schauspiel von dem sichtbaren
Wachsen der Bacillen verschaffen und die unmittelbare Ueber-
zeugung von ihrer Weiterentwickelung gewinnen. Schon nach
10 bis 15 Stunden erscheint der Inhalt der kraftigsten und am
iippigsten gewachsenen Faden fein granulirt und bald scheiden
sich in regelmassigen Abstanden sehr kleine mattglanzende
Kornchen ab, welche sich nach einigen weiteren Stunden zu den
stark lichtbrechenden eirunden Sporen vergrossern. Allmahlich
zerfallen dann die Faden, zerbrockeln an ihren Enden, die Sporen
werden frei, sinken dem Gesetze der Schwere folgend in die
unteren Schichten des Tropfens und sammeln sich hier in dichten
Haufen an. In diesem Zustande bleibt dann das Praparat
wochenlang unverandert. Die auf der Tafel XI. befindlichen
Abbildungen geben ein moglichst getreues Bild (Fig. 1 — 4) von
den eben geschilderten verschiedenen Entwickelungsstufen des
Bacillus Anthracis.
Auch in den Praparaten, welche nach dieser Methode ange-
fertigt und behandelt wurden, traten bisweilen verschiedenartige
Bacterien in grossen Schwarmen und ruhenden Colonien als
ungebetene Gaste auf und storten die Beobachtung der spateren
Entwickelungsstadien des Bacillus Anthracis. Sobald man aber
eine grossere Anzahl von Praparaten mit einiger Sorgfalt unter
Anwendung von moglichst frischem, reinem Humor aqueus oder
Blutserum und unmittelbar dem todten Thierkorper entnom-
mener Milzsubstanz anfertigt und in den Briitapparat bringt,
wird man mindestens in der Halfte, ofter in alien, bei wiederholter
7 5 6
Medical Classics
Untersuchung eine vollkommene reine Cultur von Milzbrand-
bacillen linden.; Bleibt unter den im Vorhergehenden ange-
gebenen Bedingungen die Entwickelung der Bacillen ganz aus,
oder wachsen letztere nur kummerlich und kommen nicht zur
Sporenbildung, dann liegt irgend ein Fehler in der Anordnung
des Experimentes vor Auf welche Kleinigkeiten es hierbei
unter Umstanden ankommt, mag man daraus ersehen, dass mir
anfangs manche Culturen missgliickten, weil ich alle Deckglas-
chen nach dem Gebrauch in eine Carbolsaurelosung legte und
trotz sorgfaltiger Reinigung durch den Geruch erkennbare Spuren
von Carbolsaure bisweilen an den Glaschen haften blieben.
Erst nacbdem ich mich durch Controlversuche davon uberzeugt
hatte, dass schon so ausserst geringe (p. 287) Mengen der Carbol-
saure geniigten, um die Cultur der Bacillen zu storen und demge-
masse die Glaschen immer durch mehrfaches Abspiilen von der
Carbolsaure vollstandig gereinigt hatte, blieb ich von diesen
Misserfolgen verschont. Spater wollte es mir einmal durchaus
nicht mehr gelingen, die Faden zur Sporenbildung zu bringen;
sie wuchsen in eigenthiimlichen gekrauselten, ziemlich langen
Formen, verkummerten aber schliesslich, nachdem sie nur
vereinzelte oder gar keine Sporen angesetzt hatten. Ich suchte
vergeblich den Grand in fehlerhafter Beschaffenheit des Warme-
apparates, der Nahrfliissigkeit und dergl. Endlich fiel es mir
auf, dass das zum Schliessen des Praparates benutzte Oel nach
fliichtigen Fettsauren roch und als ich nun zu gleicher Zeit
mehrere Praparate genau in gleicher Weise anfertigte, aber fur
einige ranziges Oel, fur andere tadelloses Provencerol zum Be-
festigen des Deckglases gebrauchte, kamen die Bacillen in letz-
teren zur vollkommensten Sporenbildung, in ersteren zeigten
sich nur sparliche Sporen. Da mir diese Wirkung der fliichtigen
Fettsauren, oder vielleicht nur einer bestimmten Saure, welche
nicht einmal direct mit dem die Bacillen enthaltenden Tropfen
in Beriihrung kamen, sondern nur durch ein sehr geringes Quan-
tum ihrer Dampfe darauf einwirken konnten, sehr merkwiirdig
erschien, so wiederholte ich diesen Versuch zu verschiedenen
zeiten und erhielt immer dasselbe Resultat.
3. Die Sporen des Bacillus Anthrasis eintwickeln sich unter
Untersuchungen fiber Bacterien 757
gewissen Bedingungen (bestimmte Temperatur, Nahrflussigkeit
und Luftzutritt) wieder unmittelbar zu den ursprunglich im
Blute vorkommenden Bacillen. Dass die in den langen Faden
gebildeten glanzenden Korperchen in der That Sporen sind und
nicht etwa zufallige Zersetzungsproducte oder Riickstande der
absterbenden ausgewachsenen Bacillen, Hess sich wohl schon
von vorn herein nach Analogie der Entwickelungsgeschichten
anderer Organismen aus der Reihe der Pilze und Algen mit
Bestimmtheit annehmen. Spater zu erwahnende Impfversuche
mit Fliissigkeiten, welche nur Sporen von Bacillus Anthracis
und keine Spur von Bacillen oder Faden mehr enthielten und
doch im Stande waren, mit derselben Sicherheit, wie mit frischen
Bacillen Milzbrand zu erzeugen, bestatigten diese Vermuthung.
Um aber einen vollstandigen Einblick in den Lebenslauf des
Bacillus Anthracis zu gewinnen und namentlich zu erfahren, ob
die Sporen durch eine Zwischenform, etwa eine im Wasser
lebende Schwarmspore, oder direct und in welcher Art und Weise
wieder in die Bacillen iibergehen, war es das Gerathenste, den
einmal betretenen Weg weiter (p. 288) zu verfolgen. Womoglich
musste erreicht werden, die Keimung der Sporen kiinstlich unter
Verhaltnissen vor sich gehen zu lassen, welche eine directe mikro-
skopische Beobachtung gestatten.
Alle Bemiihungen, die Sporen in destillirtem Wasser und Brun-
nenwasser zur Fortentwicklung bei gewohnlicher Temperatur
oder bei 35 0 zu bringen, schlugen fehl. In Blutserum oder
Humor aqueus nach der fruher beschriebenen Methode in ge-
schlossenen Zellen und im Briitapparat versuchte Culturen ftihr-
ten nur zu unvolkommenen Resultaten; es entwickelten sich
unzweifelhafte Bacillen, welche zu langen Faden auswuchsen und
Sporen ansetzten; aber ihre Zahl war gering und der Uebergang
einzelner Sporen in die Bacillen Hess sich in dem Sporenhaufen
nicht mit geniigender Sicherheit verfolgen. Schliesslich schlug
ich folgendes Verfahren ein, welches zum Ziele fuhrte. Es war-
den aus Praparaten, welche nach mikroskopischer Prafung eine
ganz reine Cultur von Bacillus Anthracis enthielten und nachdem
die langen Faden ganz oder grosstentheils zerfallen waren, Tropf-
chen mit Sporenmassen entnommen, auf ein Deckglas gebracht
Medical Classics
7 5 8
und theilweise dicht neben dem Rande desselben, theilweise mehr
nach der Mitte zu schnell eingetrocknet. Dieses Eintrocknen
hat den Zweck, dass die Sporenhaufchen zusammengehalten und
nicht von der Nahr-Flussigkeit auseinandergeschwemmt und
zu sehr zerstreut werden. Die Sporenmassen blieben einige
Stunden oder selbst Tage trocken; alsdann wurde auf einen
gewohnlichen (nicht hohl geschliffenen) Objecttrager ein der
Grosse des Deckglases entsprechender Tropfen Humor aqueus
gebracht und das Deckglas so aufgelegt, dass die Sporenmassen
von der Fliissigkeit benetzt wurden. Das Praparat, welches also
nicht mit Oel abgeschlossen wird, kam in den friiher beschriebenen
feuchten Raum und mit diesem in den Briitapparat, welcher eine
Warme von 35 0 hatte.
Nach einer halben Stunde fingen die hier und da noch zwischen
den Sporen liegenden Reste der ausgewachsenen Faden an, voll-
standig zu zerfallen und nach ungefahr bis 2 Stunden waren
sie verschwunden.
Schon nach 3-4 Stunden war eine Entwicklung der Sporen zu
bemerken.
In den Sporenhaufchen am Rande des Deckglases war sie am
weitesten fortgeschritten; denn sie hatten sich schon fast ganz in
Faden verwandelt; wahrend nach der Mitte des Praparates zu
alle Uebergange von diesen Faden bis zu den einfachten Sporen
sich fanden. Nach Beobachtungen an zahlreichen derartigen
Praparaten gestaltet sich der Vorgang bei der Sporenentwicklung
folgendermassen. (p. 289)
Bei genauer Untersuchung mit Starkeren Vergrosserungen
(z. B. Hartnack immers. 9) erscheint jede Spore von eiformiger
Gestalt und in eine kuglige glashelle Masse eingebettet, welche
wie ein heller schmaler, die Sporen umgebender Ring aussieht,
deren kuglige Form aber beim Rollen der Sporen nach verschied-
enen Richtungen leicht zu erkennen ist. Diese Masse verliert
zuerst ihre Kugelgestalt, sie verlangert sich in der Richtung der
Langsachse der Sporen nach der einen Seite hin und wird lang-
gezogen eiformig. Die Spore bleibt dabei in dem einen Pol des
kleinen walzenformigen Korpers liegen. Sehr bald wird die
glashelle Hulle langer und fadenformig und zu gleicher Zeit fangt
Untersuchungen iiber Bacterien 759
die Spore an ihren starken Glanz zu verlieren, sie wird schnell
blass und kleiner, zerfallt wohl auch in mehre Partieen, bis sie
schliesslich ganz verschwunden ist. In Fig. 5 ist ein solcher
Sporenhaufen mit den Uebergangen zu Faden nach einem solchen
Praparate wiedergegeben.
Spater ist es mir auch oft gelungen in demselben Praparat und
in demselben Tropfen Humor aqueus aus den Bacillen die Sporen
und sofort aus diesen wieder eine zweite Generation von sporen-
haltigen Faden zu erziehen. Wenn namlich nur wenige Bacillen
in den Tropfen gelangten, hatte sich, wie auch sonst, ungefahr
nach 20-24 Stunden die Sporenbildung vollzogen; das Nahr-
material war aber noch nicht verbraucht und einige Stunden
spater wuchsen die Sporen schon wieder zu Bacillen und diese zu
Faden aus.
Namentlich in derartigen Praparaten konnte der Uebergang
der Sporen zu den Bacillen mit Sicherheit beobachtet wercen;
die Fig. 5b. ist einem solchen Praparat entnommen und Herr
Prof. F. Cohn hatte die Giite, diese Zeichnung unter Anwendung
einer Vergrosserung mit Seibert immers. VIII. selbst anzu-
fertigen. Aus diesen hochst einfachen Formveranderungen der
Spore bei ihrer Keimung geht also hervor, dass sie aus einem
stark lichtbrechenden Tropfchen, vielleicht einem Oel, besteht,
welches von einer diinnen Protoplasmaschicht eingelhiillt ist.
Letztere ist die eigentliche entwicklungsfahige Zellsubstanz,
wahrend ersteres vielleicht einen bei der Keimung zu verbrauch-
enden Reservestoff bildet.
Mit dieser letzten Reihe von Untersuchungen ist der Kreis,
welcher von den Formveranderungen des Bacillus Anthracis ge-
bildet wird, geschlossen und damit die vollstandige Entwick-
lungsgeschichte desselben gegeben.
Da in den letzten Jahren oft die wunderbarsten Beobachtungen
und die widersprechendsten Ansichten iiber krankheitserregende
Schizophyten veroffentlicht sind und deswegen, wie ich schon
friiher (p. 290) andeutete, Arbeiten dieser Art sowohl von Bo-
tanikern als Aerzten mit einem wohl berechtigten Misstrauen
aufgenommen werden 3 so mache ich nochmals besonders darauf
aufmerksam, dass es sich bei meinen Untersuchungen nicht um
Medical Classics
760
eine zufallige, vereinzelte Beobachtung, sondern um moglichst
oft wiederholte, mit vollstandig sicherem Erfolg zu jeder Zeit
anzustellende Experimente handelt.
Um Jeden, der ein Interesse fiir die Sache hat, in den Stand zu
setzen, ohne Schwierigkeit sich selbst dutch den Augenschein von
der Richtigkeit des Resultates meiner Untersuchungen zu uber-
zeugen, habe ich die oft durch miihevolle und zeitraubendeVer-
suche gewonenen Methoden, nach denen ich gearbeitet habe,
moglichst genau beschrieben. Ganz besonderes Gewicht lege
ich ubrigens noch darauf, dass Herr Prof. F. Cohn sich auf meine
Bitte, der mich zu besonderem Danke verpflichtenden Miihe
unterzog, meine Angaben iiber die Entwicklungsgeschichte des
Bacillus Anthracis eingehend an einer Reihe von Praparaten und
von mir im pflanzenphysiologischen Institut zu Breslau ange-
stellten Experimenten zu priifen und in alien Punkten zu be-
statigen.
Die auf die Anthraxbacillen bezugliche Literatur ist mir nur
theilweise zuganglich gewesen und ich muss daher auf eine
vollstandige Angabe derselben verzichten. Nur einige Arbeiten,
welche mir erst nach Auffindung der Entwicklungsgeschichte
des Bacillus Anthracis zur Kenntniss kamen, mochte ich mit
einigen Worten beriihren. Bollinger* meint, dass die Bacillen
aus Reihen von Kugelbacterien zusammengesetzt sind, in welche
sie gelegentlich zerfallen, und dass diese Kugelbacterien allein
im Blute vorkommen, sich durch Theilung vermehren und zu
Reihen vereinigt wieder Stabchen bilden konnen. Fast konnte
es hiernach scheinen, als ob Bollinger auch die Sporenbildung
gesehen hatte. Doch ist dies nicht der Fall, denn er giebt an,
nur einmal Bacillen von 0,05 Mm. Lange gesehen zu haben, eine
Grosse, bei welcher die Bacillen noch nicht zur Sporenbildung
kommen. Auch die 1 . c. p. 465 gegebene Abbildung enthalt nur
abgestorbene Bacillen, auf deren Form ich spater zuriickkomme.
Im dritten Hefte des ersten Bandes dieser Beitrage p. 200 aus-
sert F. Cohn bei der Besprechung der eben angefuhrten Angaben
Bollinger's, dass er die Milzbrandstabchen dennoch fur Bacillen
halte und dass man nach Analogie anderer Bacillen eine Fort-
* Zieinssen*s Handb. der spec. Pathol, und Therap. Bd. 3. p. 464.
Untersuchungen iiber Bacterien 761
pflanzung derselben durch kugelige Dauersporen erwarten miisse;
eine (p. 291) Vermuthung, welche sich sehr bald verwirklicht
hat. Die neueste Veroffentlichung iiber Milzbrandbacterien,
welche von C. 0 . Harz herriihrt, enthalt nach dem mir vorliegen-
den Referat (Allgem. med. Centralzeitung 1876 No. 33) nur
negative Resultate, welche den von mir erhaltenen positiven
gegeniiber ihre Bedeutung verlieren miissen.
III. Biologie des Bacillus Anthracis. Die Moglichkeit, den
Bacillus Anthracis unter kiinstlichen Verhaltnissen zu sporen-
haltigen Faden und seine Sporen wieder zu Bacillen zu ent-
wickeln, beweist natiirlich noch nicht, dass das Vorkommen des
Milzbrandes unter alien Umstanden auf die verschiedenen Ent-
wickelungsformen dieser Bacterienart zuriickgefiihrt werden
miisse. Da er im lebenden Organismus, wie friiher gezeigt wurde
(allerdings vorlaufig nur fiir die Thierspecies, mit welcher experi-
mentirt wurde, beweisend), sich nicht weiter entwickelt, so kann
nur durch Versuche iiber das Verhalten des Bacillus Anthracis
unter Bedingungen, welchen er auf seinem muthmasslichen Wege
nach dem Absterben des von ihm bewohnten Thieres unter-
worfen ist, eine Aufklarung hieriiber gesucht werden.
Um nicht zu ausfiihrlich zu werden, muss ich die sehr umfang-
reichen in dieser Richtung angestellten Versuchsreihen kurz
zusammenfassen.
Substanzen, welche Milzbrandbacillen enthalten, konnen in
trockenem Zustande oder in Flussigkeiten suspendirt verbreitet
werden. Dass sie eingetrocknet Iange Zeit wirksam sein konnen,
war schon bekannt; doch schwanken die Angaben iiber die Dauer
dieser Wirksamkeit. Um diese letzteren genauer zu bestimmen,
wurden folgende Versuche gem acht:
Milz, Lymphdriisen, Blut von Mausen, Kaninchen und Meer-
schweinchen \vurden sofort, nachedm sie dem Thierkorper ent-
nomen waren, an einem schattigen luftigen Ort getrocknet, und
zwar in grosseren Stiicken, in kleineren ungefahr erbsen- bis
hiersckorngrossen Massen und in am Deckglase eingetrockneten
dunnen Schichten. Mit diesem Material wurde anfangs taglich,
spater von zwei zu zwei Xa gen zu gleicher Zeit, nachdem eine
entsprechende Menge in Humor aqueus aufgeweicht war, eine
762 Medical Classics
oder mehrere Mause geimpft und ein Culturversuch in einer
Paraffinzelle gemacht. Die in sehr diinnen Lagen eingetrock-
neten Bacillenmassen verloren, je nach ihrer Dicke, nach 12-30
Stunden ihre Impffahigkeit und ebenso auch die Moglichkeit, im
Brutapparat zu langen Faden heranzuwachsen. Unmittelbar
nach dem Anfeuchten hatten die Bacillen dasselbe Aussehen,
wie im frischen Zustande; aber sie zerfielen sehr bald unter
spater genauer zu beschreibenden Veranderungen, sei waren also,
nachdem (p. 292) sie einen gewissen Theil ihrer Feuchtigkeit
verloren hatten, abgestorben. Dickere getrocknete Stiicke hiel-
ten sich zwei bis drei Wochen impf- und entwickelungsfahig.
Noch grossere behielten ihre Wirksamkeit, offenbar weil sie
langsamer vollkommener lufttrocken werden, gegen vier bis funf
Wochen. Aber langere Zeit hindurch frisch getrocknete bacil-
lenhaltige Massen impffahig zu erhalten, ist mir nie gelungen,
obwohl ich diese Versuche in der verschiedensten Weise modificirt
und wiederholt habe, weil ich, auf Davaine’s Angaben mich
verlassend, anfangs bestimmt glaubte, mir auf diese Weise frisch
erhaltene Milzbrandsubstanzen fur spatere Versuche sichern zu
konnen; doch wurde ich stets auf das Empfindlichste getauscht
und musste meine Arbeiten deswegen mehrfach unterbrechen,
bis es mir spater gelang, in anderer Weise einen stets wirksamen
Impstoff zu gewinnen und mich dadurch vom Zufall unabhangig
zu machen.
Auf eine Erscheinung, welche bei dieser Versuchsreihe recht
auffallend hervortrat, muss ich noch besonders aufmerksam
machen, dass namlich nur solche getrocknete Substancen Milz-
brand hervorriefen, aus welchen bei den gleichzeitig angestellten
Culturversuchen sich sporenhaltige Faden entwickelten und
umgekehrt. Es wiirde diese Beobachtung allein schon geniigen,
um die directe Uebertragbarkeit des Milzbrandes als von dem
A'orhandensein lebensfahiger Bacillen abhangig zu beweisen.
Ehe ich zu den Versuchen liber Milzbrandfliissigkeiten iiber-
gehe, muss ich eine Reihe von Culturversuchen bei verschiedenen
Temperaturen envahnen. Es war mir hauptsachlich darum zu
thun, die unterste Temperaturgrenze zu finden, bei welchen der
Bacillus Anthracis noch keimfahige Sporen zu entwickeln vermag.
Untersuchungen iiber Bacterien 763
Es wurden also eine Anzahl Paraffinzellen in der friiher beschrie-
benen Weise mit Nahrfliissigkeit und frischen lebenskraftigen
Bacillen beschickt und bei verschiedenen Temperaturen aufbe-
wahrt. Da dieses Experiment wahrend des Winters angestellt
wurde, so war es mir leicht, einzelne Praparate in einem bis auf
5 0 abgekiihlten Raum zu halten. Die hoheren Temperaturen
(iiber 40°) wurden vermittelst des heizbaren Objecttisches er-
halten. Hierbei stellte sich heraus, dass die Faden am schnell-
sten bei 35° wachsen; schon nach 20 Stunden konnen sie bei
dieser Temperatur mit den schonsten Sporen versehen sein.
Bei 30° zeigen sich die Sporen etwas spater, namlich nach unge-
fahr 30 Stunden. Bei noch niedrigerer Temperatur wird auch
die Entwickelung der Bacillen entsprechend langsamer. Bei
18-20° (p. 293) (Cels.), also gewohnlicher Zimmertemperatur,
brauchen sie ungefahr zwei und einen halben bis drei Tage zur
Sporenentwickelung. Unter 18° kommt es nur noch ausnahms-
weise zur Sporenbildung und unter 12° habe ich iiberhaupt kein
Wachsthum der Faden mehr beobachtet. Ueber 40° wird dei
Entwickelung der Bacillen kummerlich und schien mir bei 45°
aufzuhoren; doch habe ich die Versuche iiber die oberen Tem-
peraturgrenzen fur das Wachsthum der Bacillen nicht oft genug
wiederholt (da der heizbare Objecttisch immer nur die Beo-
bachtung eines einzelnen Praparates zulasst), um dieselbe ganz
genau angeben zu konnen.
Ich komme nun auf das fur die Aetiologie des Milzbrandes so
ausserst wichtige Verhalten der Bacillen in verschiedenen Fliis-
sigkeiten und unter moglichst naturlichen Bedingungen. Da
von dem mir zu Gebot stehenden Versuchsthier, der Maus, nur
ein sehr geringes Quantum Blut zu erhalten war und dieses Blut
ausserdem noch sehr wenige Bacillen enthalt, so nahm ich frisches
Rinderblut oder den von mir mit Vorliebe gebrauchten Humor
aqtieus, eingemale auch Glaskorper von Rinderaugen und zerrieb
in diesen Fliissigkeiten frische bacillenhaltige Mausemilz, so
dass das Gemenge in der Zusammensetzung ungefahr dem Blute,
serosen und schleimigen Fliissigkeiten von an Milzbrand gefal-
lenen Thieren glich.
Derartige Fliissigkeiten in ein gut verkorktes Glas gefullt.
Medical Classics
762
Oder mehrere Mause geimpft und ein Culturversuch in einer
ParaffinzeUe gemacht. Die in sehr dunnen Lagen eingetrock-
neten Bacillenmassen verloren, je nach ihrer Dicke, nach 12-30
Stunden ihre Impffahigkeit und ebenso auch die Moglichkeit, im
Briitapparat zu langen Faden heranzuwachsen. Unmittelbar
nach dem Anfeuchten hatten die Baciilen dasselbe Aussehen,
wie im frischen Zustande; aber sie zerfielen sehr bald unter
spater genauer zu beschreibenden Veranderungen, sei waren also,
nachdem (p. 292) sie einen gewissen Theil ihrer Feuchtigkeit
verloren hatten, abgestorben. Dickere getrocknete Stiicke hiel-
ten sich zwei bis drei Wochen impf- und entwickelungsfahig.
Noch grossere behielten ihre Wirksamkeit, offenbar weil sie
langsamer vollkommener lufttrocken werden, gegen vier bis funf
Wochen. Aber langere Zeit hindurch frisch getrocknete bacil-
lenhaltige Massen impffahig zu erhalten, ist mir nie gelungen,
obwohl ich diese Versuche in der verschiedensten Weise modificirt
und wiederholt habe, weil ich, auf Davaine’s Angaben mich
verlassend, anfangs bestimmt glaubte, mir auf diese Weise frisch
erhaltene Milzbrandsubstanzen fur spatere Versuche sichern zu
konnen; doch wurde ich stets auf das Empfindlichste getauscht
und musste meine Arbeiten deswegen mehrfach unterbrechen,
bis es mir spater gelang, in anderer Weise einen stets wirksamen
Impstoff zu gewinnen und mich dadurch vom Zufall unabhangig
zu machen.
Auf eine Erscheinung, welche bei dieser Versuchsreihe recht
auffallend hervortrat, muss ich noch besonders aufmerksam
machen, dass namlich nur solche getrocknete Substancen Milz-
brand hervorriefen, aus welchen bei den gleichzeitig angestellten
Culturversuchen sich sporenhaltige Faden entwickelten und
umgekehrt. Es wiirde diese Beobachtung allein schon genugen,
um die directe Uebertragbarkeit des Milzbrandes als von dem
Vorhandensein lebensfahiger Baciilen abhangig zu beweisen.
Ehe ich zu den Versuchen uber Milzbrandfliissigkeiten iiber-
gehe, muss ich eine Reihe von Culturversuchen bei verschiedenen
Temperaturen envahnen. Es war mir hauptsachlich darum zu
thun, die unterste Temperaturgrenze zu finden, bei welchen der
Bacillus Anthracis noch keimfahige Sporen zu entwickeln vermag.
Untersuchungen iiber Bacterien 763
Es wurden also eine Anzahl Paraffinzellen in der friiher beschrie-
benen Weise mit Nahrfliissigkeit und frischen lebenskraftigen
Bacillen beschickt und bei verschiedenen Temperaturen aufbe-
wahrt. Da dieses Experiment wahrend des Winters angestellt
wurde, so war es mir leicht, einzelne Praparate in einem bis auf
5 0 abgekiihlten Raum zu halten. Die hoheren Temperaturen
(iiber 40°) wurden vermittelst des heizbaren Objecttisches er-
halten. Hierbei stellte sich heraus, dass die Faden am schnell-
sten bei 35° wachsen; schon nach 20 Stunden konnen sie bei
dieser Temperatur mit den schonsten Sporen versehen sein.
Bei 30° zeigen sich die Sporen etwas spater, namlich nach unge-
fahr 30 Stunden. Bei noch niedrigerer Temperatur wird auch
die Entwickelung der Bacillen entsprechend langsamer. Bei
18-20° (p. 293) (Cels.), also gewohnlicher Zimmertemperatur,
brauchen sie ungefahr zwei und einen halben bis drei Tage zur
Sporenentwickelung. Unter l8° kommt es nur noch ausnahms-
weise zur Sporenbildung und unter 12° habe ich iiberhaupt kein
Wachsthum der Faden mehr beobachtet. Ueber 40° wird dei
Entwickelung der Bacillen kiimmerlich und schien mir bei 45°
aufzuhoren; doch habe ich die Versuche iiber die oberen Tem-
peraturgrenzen fur das Wachsthum der Bacillen nicht oft genug
wiederholt (da der heizbare Objecttisch immer nur die Beo-
bachtung eines einzelnen Praparates zulasst), um dieselbe ganz
genau angeben zu konnen.
Ich komrrie nun auf das fur die Aetiologie des Milzbrandes so
ausserst wichtige Verhalten der Bacillen in verschiedenen Fliis-
sigkeiten und unter moglichst natiirlichen Bedingungen. Da
von dem mir zu Gebot stehenden Versuchsthier, der Maus, nur
ein sehr geringes Quantum Blut zu erhalten war und dieses Blut
ausserdem noch sehr wenige Bacillen enthalt, so nahm ich frisches
Rinderblut oder den von mir mit Vorliebe gebrauchten Humor
aqueus , eingemale auch Glaskorper von Rinderaugen und zerrieb
in diesen Fliissigkeiten frische bacillenhaltige Mausemilz, so
dass das Gemenge in der Zusammensetzung ungefahr dem Blute,
serosen und schleimigen Fliissigkeiten von an Milzbrand gefal-
lenen Thieren glich.
Derartige Fliissigkeiten in ein gut verkorktes Glas gefullt,
764 Medical Classics
nehmen im Brutapparat sehr schnell einen hochst penetranten
Faulnissgeruch an. Die Bacillen sind schon nach 24 Stunden
verschwunden, ohne dass sie zu Faden ausgewachsen waren und
es gelingt dann nicht mehr, damit Miizbrand zu erzeugen. Da-
von dass das Absterben der Bacillen in diesem Falle weniger von
dem Einfluss der sich entwickelnden Faulnissgase, weiche nicht
entweichen konnen, sondern von dem Mangel an Sauerstoff ab-
hangt, kann man sich leicht durch folgendes Experiment iiber-
zeugen. Ein zwischen einem gewohnlichen Objecttrager und
Deckglas ohne Luftblasen befindlicher bacillenhaltiger Blut-
stropfen wird durch eine auf den Rand gepinselte Oelschicht
luftdicht eingeschlossen und auf dem heizbaren Objecttisch
erwarmt. Das Blut zeigt mit dem Mikrospektroskop untersucht
anfangs die beiden Streifen des Oxyhamoglobin; dabei fangen die
Bacillen ganz wie in den Zellenpraparaten, an sich zu verlangern
und erreichen nach ungefahr drei Stunden die 4-5 fache Lange.
Dann ist der SaueYstoff verbraucht, es verschwinden die beiden
Streifen und es erscheint dafiir der zwischen beiden liegende
Streifen des reducirten Hamoglobin. Von diesem Zeitpunkte
an hort auch das weitere Wachsthum der Bacillen vollstandig
auf, obwohl noch (p. 294) keine Faulnissbacterien bemerkt wer-
den und die eigentliche Faulniss noch nicht eingetreten ist.* An
einem solchen Praparate kann man, wenn es bei niedriger Tem-
peratur gehalten wird, in vorziiglicher Weise die Veranderungen
der Bacillen beim Absterben studiren. Dieser Vorgang gestaltet
sich folgendermassen. Wahrend frische Bacillen und im krafti-
gen Wachsthum befindliche (mit Ausnahme des Zeitpunktes
dicht vor der Sporenbildung) immer einen homogenen glashellen
Inhalt haben und nur ganz vereinzelt eine sonst nur durch wink-
lige Knickungen angedeutete Gliederung zeigen, erkennt man in
den absterbenden Bacillen als erstes Symptom eine Triibung des
Inhalts und eine Sonderung desselben in kiirzere Abtheilungen.
Die Bacillen erscheinen dann mehr oder weniger deutlich geglie-
* Im nicht gcofrneren Korper eines an Miizbrand gestorbenen Thieres verlangern sich
die Bacillen, auch ■wenn der Cadaver langere Zeit bei einer Temperatur von 18-20° ge-
Iassen wird, nur sehr vrenig oder gar nicht; offenbar weil der Sauerstoff des Blutes nach
Tode schnell durch Oxydations-processe verbraucht und nicht wieder ersetzt wird.
Untersuchungen iiber Bacterien 765
dert, namentlich so lange noch die ausserst feine Zellenmembran
diese Theile scheidernartig umhiillt und zusammenhalt. Aber
sehr bald verlieren die Bacillen ihre scharfen Contouren, sie
scheinen aus kurzen, rundlichen, lose zusammenhangenden
Stiickchen zu bestehen und zerfallen schliesslich vollstandig.
Die mir vorliegende Abbildung Bollinger’s ( 1 . c. p. 465) ist eine
ziemlich getreue Darstellung solcher abgestorbener Bacillen.
Ich habe einzelne in dieser Weise zerfallende Bacillen in den
verschiedensten Praparaten oft tagelang von Zeit zu Zeit beo-
bachtet, habe aber niemals einen Uebergang derselben in Micro-
coccen oder dergleichen gesehen.
Ganz andere Bilder gewahren dagegen bei ofters wiederholter
Untersuchung die genannten bacillenhaltigen Flussigkeiten, wenn
der Zutritt von Sauerstoff, und sei es auch nur in sehr geringer
Menge, gestattet wird und ihre Temperatur nicht dauernd unter
1 8° herabsinkt. Sehr gut lassen sich die hierbei eintretenden
Veranderungen verfolgen, wenn ungefahr 10-20 Gramm der
Fliissigkeit in einem Uhrglase, auf welches eine nicht festschlies-
sende Glasplatte aufgelegt wird, mehrere Tage bei Zimmertem-
.peratur bleiben. Die Fliissigkeit nimmt schon nach 24 Stunden
Faulnissgeruch an, der nach weiteren 24 Stunden gewohnlich
sehr penetrant ist. Dem entsprechend finden sich auch sehr
bald Micrococcen und Bacterien in grosser Me.ige. Daneben
aber gedeiht der Bacillus Anthracis so gut, als ob er der alleinige
Bewohner der Nahrfliissigkeit ware. Seine Faden erreichen
schon nach 24 Stunden eine betrachtliche (p. 295) Lange und
haben offers schon nach 48 Stunden und selbst noch zeitiger
Spores in grosser Menge angesetzt.* Nach der Sporenentwick-
lung zerfallen die Faden und die Sporen sinken zu Boden. Die
Vegetation der iibrigen Schizophyten, welche zufallig in die
Fliissigkeit eindrangen und sich darin vermehrten, geht noch
Tage lang in iippigster Weise weiter. Allmahlich aber ver-
schwinden auch diese, der charakteristische Faulnissgeruch
nimmt ab, schliesslich bildet sich ein schlammiger Bodensatz und
In Paraffinzellen zu gleicher Zeit und unter denselben Verhaltnissen gezuchtete
Bacillen wuchsen langsamer und kummerlicher. Vielleicht wegen des erheblich gerin-
geren Sauers tofFvorraths.
7 66 Medical Classics .
die dariiber stehende Flussigkeit wird arm an geformten Bestand-
theilen und fast klar. Sie hat zuletzt einen schwachen Geruch
nach Leim oder Kase, verandert sich, wenn sie bisweilen durch
den Zusatz von destillirtem Wasser vor dem Austrocknen ge-
schiitzt wird, nicht mehr und ist vollstandig ausgefault.
Wurden bacillenhaltige Substanzen mit destillirtem oder Brun-
nenwasser massig verdiinnt, dann verhindert das die Sporen-
bildung nicht; aber bei starkerer Verdiinnung entwickeln sich
die Bacillen nicht mehr,* sie sterben bald ab und erzeugen
ungefahr nach 30 Stunden eingeimpft keinen Milzbrand mehr.
Die Nahrfliissigkeit muss also eine gewisse noch naher zu bestim-
mende Menge an Salzen und Eiweiss enthalten, damit die Bacillen
bis zur Sporenbildung kommen konnen.
Es unterliegt wohl keinem Zweifel, dass die meisten Cadaver
der an Milzbrand gefallenen Thiere, welche im Sommer massig
tief eingescharrt werden, oder langere Zeit auf dem Felde, im
Stalle, in Abdeckereien liegen, ebenso die blut- und bacillen-
haltigen Abgange der kranken Thiere im feuchten Boden oder im
Stalldiinger mindestens ebenso giinstige Bedingungen fur die
Sporenbildung des Bacillus Anthracis bieten, als es in den vorher
geschilderten Versuchsreihen der Fall ist. Durch diese Experi-
mente wiirde also der Beweis geliefert sein, dass nicht bios durch
kunsdiche Ziichtung im Ausnahmefalle die Sporen des Bacillus
Anthracis entstehen, sondern dass dieser Parasit in jedem Sommer
im Boden, dessen Feuchtigkeit das Austrocknen der den Hoh-
lungen des noch lebenden oder schon abgestorbenen milzbrandi-
gen Thieres entstromenden Nohrfliissigkeit verhindert, seine
Keime in unzahlbarer Menge ablagert.
Dass sich diese Keime im Wasser nicht verandern, aber in (p.
296) Humor aqueus und Blutserum wieder zu Bacillen heran-
wachsen, haben wir fruher gesehen. Da liesse sich wohl schon
von vornherein annehmen, dass, wenn von diesen Sporen auf
irgend einem Wege eineoder auch mehrere in den Blutstrom eines
fiir Milzbrand empfanglichen Thieres gelangt, hier eine neue
Generation von Bacillen erzeugt wird. Um diese Annahme auch
z-B. Bacillen in Mausemilz mit dem zwanzigfachen Quantum destillirten Wassers
verdunnt, wuchsen nicht.
Untersuchungen iiber Bacterien 767
experimentell zu prii fen, wurden noch folgende Versuche ange-
stellt.
Von zwei mit bacillenhaltigen Blutserum gefullten, verdeckten
Uhrglasern blieb das eine im Zimmer, das andere wurde in einem
kalten Raume (8°) aufbewahrt und von beiden taglich zwei
Thiere geimpft. Im Blutserum, welches kalt stand, fingen die
Bacillen am dritten Tage an kornig und gegliedert zu werden,
bis dahin war es wirksam; die spater damit geimpften Thiere
blieben gesund. Die Impfungen mit dem warmstehenden Blut-
serum waren vor und nach der. Sporenbildung in den Faden des
Bacillus Anthracis wirksam; selbst nach 14 Tagen liess sich mit
solchem gefaulten Blute, welches Bacillen-Sporen enthalt, noch
mit derselben Sicherheit Milzbrand erzeugen, wie mit frischer
stabchenhaltiger Milz. Die Sporen scheinen sich sehr lange Zeit
in faulenden Fliissigkeiten ebenso gut, wie in nicht faulenden,
'keimfahig zu erhalten. Denn mit Glaskorper von Rinderaugen,
in welchem ich bei ungefahr 10° Bacillen aus einer Mausemilz zur
Sporenbildung kommen liess und welcher nach drei Wochen
vollstandig ausgefault war, konnte noch nach eilf Wochen mit
absoluter Sicherheit durch Impfung Milzbrand hervorgerufen
werden. Der Bodensatz dieser ausgefaulten Fliissigkeit enthielt
sehr viele von kleinen Schleimflocken zusammengehaltene Ba-
cillen-Sporen, wahrend man in der fast klaren Fliissigkeit bei
mikroskopischer Untersuchung oft mehrere Gesichtsfelder durch-
suchen musste, ehe man einige vereinzelte Sporen fand. Von
Faden war natiirlich nicht das Geringste mehr vorhanden. Bei
den Impfungen mit dem sporenreichen Bodensatz und mit der
sporenarmen Fliissigkeit stellte sich die interessante Thatsache
heraus, dass mit ersterem also mit vielen Sporen geimpfte Mause
nach 24 Stunden, mit letzterer also mit weniger Sporen geimpfte
Mause nach drei bis vier Tagen an Milzbrand starben. Ich
bemerke noch besonders, dass ich diesen Versuch mehrere Male
und immer mit demselben Erfolg wiederholt habe.
Sporenhaltige Flocken derselben Fliissigkeit wurden drei
Wochen in einem mitt Brunnenwasser gefullten offenen Reagens-
glase aufbewahrt; trotzdem blieben dieselben wirksam bei der
damit vorgenommenen Impfung.
Medical Classics
768
(p. 297) Ebensolche sporenhaltige Substanzen wurden ge-
trocknet, nach einiger Zeit mit Wasser wieder aufgeweicht und
dieser Procedur wiederholt unterworfen; aber sie verloren inre
Fahigkeit Milzbrand zu erzeugen, dadurch nicht.
Hiernach wird es nun auch leicht erklarlich, warum die Meinun-
gen der Experimentatoren uber die Wirksamkeit des getrockneten
Milzbrandblutes so weit auseinandergehen; da der Eine frisches,
schnell getrocknetes Blut benutzte, welches keine Sporen enthielt
und, wie ich fruher gezeigt habe, sich hochstens fiinf Wochen
wirksam erhalt; von Anderen dagegen wurde mit Blut geimpft,
das langsam bei Zimmer- oder Sommer-Temperatur eingetrocknet
war und in welchem sich Sporen gebildet hatten. Ich besitze eine
kleine Sammlung von Milzbrandsubstanzen, welche unter den
verschiedensten Umstanden und zu verschiedenen Zeiten getrock-
net und in unverstopselten, enghalsigen Glasern aufbewahrt sind.
Als ich auf die Bedeutung der Sporen in getrockneten Milzbrand-
massen aufmerksam wurde, untersuchte ich diese getrockneten
Blut-, Milz- und Drusenstiickchen nochmals genau auf ihre
Fahigkeit, mit Humor aqueus aufgeweicht in Glaszellen die char-
akteristischen sporenhaltigen Faden des Bacillus Anthracis und
bei der Impfund Milzbrand entstehen zu lassen. Hierbei stellte
sich heraus, dass die in kleinen Stricken schnell getrockneten
Theile keine Sporen enthielten und weder Faden noch Milzbrand
hervorzubringen vermochten. Schafmilz dagegen, welche in
grosseren Stricken im Zimmer langsam getrocknet war, und einige
Blutproben, welche in grosseren Quantitaten aufgestellt gewesen
waren und mehrere Tage zum vollstandigen Eintrocknen ge-
braucht hatten, enthielten zahlreiche mehr oder weniger freie
Sporen und Bruchstiicke von sporenhaltigen Faden. Alle diese
sporenhaltigen Substanzen riefen nach der Einimpfung Milzbrand
hervor und entwickelten in Nahrfliissigkeiten oft die schonsten
sporenhaltigen Faden von Bacillus Anthracis. Wie lange sich
die getrockneten Sporen keimfahig halten, lasst sich zur Zeit
nicht mit Bestimmtheit angeben; wahrscheinlich wird dieser
Zeitraum eine langere Reihe von Jahren umfassen; wenigstens
habe ich mit Schafblut, welches vor fast vier Jahren getrocknet
Untersuchungen iiber Bacterien 769
ist, noch in letzter Zeit vielfach Impfungen ausgefuhrt, welche
ausnahmslos todtlichen Milzbrand bewirkten.*
Mehrfach ist die Identitat der durch Impfungen mit Milzbrand-
blut hervorgerufenen Krankheit mit Septicamie und ebenso das
(p. 298) umgekehrte Verhaltniss behauptet worden. Um diesen
Einwand, der moglicherweise auch meinen mit faulenden Milz-
brandsubstanzen angestellten Impfversuchen gemacht werden
konnte, zu begegnen, habe ich mit faulendem Blute von gesunden
Thieren mit bacillenfreiem faulenden Humor aqueus und Glas-
korper Mause mehrfach geimpft. Dieselben blieben fast immer
gesund, nur zwei Mause starben von zwolf geimpften, und zwar
einige Tage nach der Impfung; sie hatten vergrosserte Milz, aber
diese sowohl wie das Blut waren vollstandig frei von Bacillen.
Ferner wurden Thiere mit faulendem Glaskorper geimpft, in
welchem sich eine dem Bacillus Anthracis sehr ahnliche Bacil-
lusart spontan entwickelt hatte. Die Sporen der beiden Bacillus-
arten waren weder in Grosse noch sonstigem Aussehen von einan-
der zu unterscheiden; nur die Faden des Glaskorper-Bacillus
waren kiirzer und deutlich gegliedert. Alle Impfungen mit diesen
mehrmals von mir auf Glaskorper gefundenen Bacillen und mit
ihren Sporen vermochten keinen Milzbrand zu erzeugen. Auch
solche Thiere, welche mit Sporen der im Heu-Infus von Prof. F.
Cohn geziichteten Bacillen igeimpft wurden, blieben gesund.
Dagegen habe ich mehrfach mit Sporenmassen, welche in Glas-
zellen gezii elite t waren und wie ich mich vorher durch mikro-
skopische Untersuchungen versicherte, aus ganz reinen Culturen
von Bacillus Anthracis stammten, geimpft und jedesmal starben
die geimpften Thiere an Milzbrand. Es folgt hieraus, dass nur
eine Bacillusart im Stande ist, diesen specifischen Krankheits-
process zu vernalassen, wahrend andere Schizophyten durch
Impfung gar nicht oder in anderer Weis'e krankheitserregend
wirken. Es konnte auffallend erscheinen, dass von meinen mit
faulendem Blute geimpften Versuchsthieren nur ausnahmsweise
Die beim Bearbeiten von Hauten, Haaren und dergl. entstandenen Milzbrander-
krankungen bei Menschen, konnen, wenn diese Gegenstande schon vor Jahren getrocknet
nur durch sporenhaltige Staubtheile veranlasst sein.
Medical Classics
77 °
eins an Septicamie zu Grunde ging; dem gegenuber bemerke ich,
dass ich nicht, wie es gewohnlich iiblich ist, das faulende Blut
nach Cubikcentimeteren einspritzte, sondern nur eine verschwind-
end kleine Menge desselben dem Korper des Thieres einimpfte
und damit natiirlich die Wahrscheinlichkeit, die im Blute viel-
leicht sparsam vorhandenen septisch wirkenden Formelemente
in den Blutstrom zu bringen, sehr verringert wird.
Dass die Sporen des Bacillus Antkracis Milzbrand hervorrufen,
wenn sie direkte in den Saftestrom des Thierkorpers gebracht
werden, ist durch die zuletzt besprochenen Versuche wohl hin-
reichend bewiesen. Die Sporen miissen also wirksam werden,
sobald sie in getrocknetem Zustande als Staubpartikelchen oder
in Fliissigkeiten suspendirt auf Wunden, wenn diese auch noch
so klein sind, gelangen. Man diirfte wohl kaum eines unsrer
Hausthiere finden, dessen Haut (p. 299) nicht mit einigen Kratz-
wunden oder kleinen durch Scheuern, Reiben und dergl. ent-
standenen Hautabscharfungen versehen ist und damit dem
gefahrlichen Schmarotzer einen bequemen Eingang darbietet.
Trotzdem ist damit noch nicht gesagt, dass die Milzbrandsporen
nur auf diesem Wege einzuwandern vermogen. Es mussen, um
die Milzbrandatiologie vollstandig zu haben, auch die Ver-
dauungswege und die Respirationsorgane auf ihre Resorptions-
fahigkeit fur Milzbrandbacillen und deren Sporen untersucht
werden.
Um zu sehen, ob das Milzbrandcontagium vom Yerdauungs-
kanal aus in den Korper eindringen kann, habe ich zuert Mause
mehrere Tage lang mit frischer Milz von Kaninchen und vom
Schaf, welche an Milzbrand gestorben waren, gefiittert. Mause
sind ausserordentlich gefrassig und nehmen in kurzer Zeit mehr
als ihr Korpergewicht betragt, an milzbrandigen Massen auf, so
dass also ganz erhebliche Mengen von Bacillen den Magen und
Darm der Versuchsthiere passirten. Aber es gelang mir nicht,
dieselben auf diese Weise zu inficiren. Dann mangte ich den
Thieren sporenhaltige Fliissi gkei t unter das Futter; auch das
frassen sie ohne jeden Nachtheil; auch durch Futterung grosserer
Mengen von sporenhaltigem, kurz vorher oder schon vor Jahren
getrocknetem Blute konnte kein Milzbrand bei ihnen erzeugt
Untersuchungen liber Bacterien 771
werden. Kaninchen, welche zu verschiedenen Zeiten mit sporen-
haltigen Massen gefuttert wurden, blieben ebenfalls gesund.
Fiir diese beiden Thierspecies scheint demnach eine Infection
vom Darmkanal aus nicht moglich zu sein.
Ueber das Verhalten der mit Staub in die Athmungsorgane ge-
langten Sporen vermag ich bis jetzt nichts anzugeben, da es mir
noch nicht moglich war, darauf bezugliche Versuche anzustellen.
Ich schliesse hier noch einige Versuchsreihen und Beobachtun-
gen an, welche nicht direct mit der Aetiologie des Milzbrandes in
Verbindung stehen, aber doch Interesse genug bieten, um mit-
getheilt zu werden.
Den schon von Brauell gemachten Versuch, sowohl mit dem
bacillenhaltigen Blute trachtiger Thiere, als mit dem bacillen-
freien Blute des Fotus derselben zu impfen, habe ich mit einem
trachtigen Meerschweinchen und zwei trachtigen Mausen wieder-
holt. Das Resultat war das namliche, wie bei dem Experiment
von Brauell; die mit dem mutterlichen Blute geimpften Thiere
starben an Milzbrand, die mit dem fotalen Blute geimpften
blieben gesund. Um zu sehen, wie bald nach der Impfung die
ersten Bacillen im Blute oder in der Milz der geimpften Thiere
sich einfinden, wurden neun Mause zu gleicher Zeit geimpft.
Nach zwei, vier, sechs, acht, zehn, zwolf, (p. 300) vierzehn und
sechszehn Stunden wurde jedesmal eine dieser Mause durch
Chloroform getodtet und Blut sowohl als Milz sofort untersucht.
In den sechs ersten Thieren wurden keine Bacillen gefunden.
Erst in der Milz der vierzehn Stunden nach der Impfung ge-
todteten Maus zeigten sich vereinzelte Bacillen. Bei der Maus,
welche sechszehn Stunden gelebt hatte, fanden sich schon mehr
Bacillen und die Milz war vergrossert. Die letzte starb nach
siebzehn Stunden unter den gewohnlichen charakteristischen
Symptomen; ihre Milz war erheblich vergrossert und vollgestopft
mit dichten Bacillenmassen. Das Eindringen der Bacillen in den
Blutstrom scheint also langsam vor sich zu gehen, aber wenn sie
erst einmal hineingelangt sind und hier in ihrer eigentlichen
Heimath festen Fuss gefasst haben, vermehren sie sich in der
iippigsten Weise.
Ausser an Mausen, Kaninchen und Meerschweinchen habe
772 Medical Classics
ich Impfversuche an zwei Hunden, einem Rebhuhn und einem
Sperling gemacht. Obwohl ich diese Thiere wiederholt mit ganz
frischem Material impfte, so ist es mir doch nicht gelungen, sie
mit Milzbrand zu inficiren.
Auch Frosche sind ganz unempfanglich fiir Impfungen mit
Bacillus Anthracis oder dessen Sporen. Als ich einigen Froschen
grossere Stiicke Milz von an Milzbrand gestorbenen Mausen unter
die Riickenhaut brachte, die Thiere nach 48 Stunden todtete und
untersuchte, stellte sich folgender bemerkenswerthe Befund
heraus. Das Blut der Frosche war vollkommen frei von Bacillen.
Die Mausemilz war mit ihrer Umgebung leicht verklebt und
hatte statt ihrer dunkelbraunrothen Farbe eine mehr hellgrau-
rothe angenommen. Bei der mikroskopischen Untersuchung
derselben finden sich in der Mitte noch unveranderte Bacillen in
grosser Menge, aber in den ausseren Schichten trifft man auf
viele Bacillen, welche dicker geworden sind und sich verlangert
haben, und zwischen diesen sieht man eigenthiimliche Gebilde
in grosser Zahl; namlich mehr oder weniger regelmassig spiral-
formig gewundene Bacillen, welche theils frei sind, theils aber
auch von einer sehr diinnwandigen Kapsel eingeschlossen werden.
Die Erklarung fur diese ungewohnliche Gestaltung der Bacillen
ist leicht zu finden, wenn man die fast gallertartige, anscheinend
von der Froschhaut ausgeschiedene ausserste Umhiillungsschicht
der Milz untersucht (Fig. 7). Diese Schicht besteht aus grossen,
in eine strukturlose zahfliissige Grundsubstanz eingebetteten
Zellen, welche fast die Grosse Grundsubstanz eingebetteten Zel-
len, welche fast die Grosse der Froschblutkorperchen erreichen
(Fig. 7a). Dieselben sind trotz ihrer Grosse sehr blass und zart,
haben einen sehr deutlichen Kern mit Kernkorperchen und
enthalten viele sehr kleine, (p. 301) in lebhaftester Molekul-
arbewegung befindliche Kornchen. In den meisten von diesen
Zellen nun befinden sich einzelne oder mehrere Kurze gerade
Bacillen, in anderen etwas gekriimmte, geknickte, zu Haiifen
und Biindeln vereinigte und vorzugsweise spiralformig gedrehte
Bacillen (Fig. 7b). Sobald die Zellen mehrere Bacillen beher-
bergen, erscheinen die Molekularkornchen in ihnen vergrossert,
nimmt aber die Bacillenwucherung in ihnen iiberhand, dann ver-
Untersuchungen iiber Bacterien 773
schwinden diese Kornchen und zuletzt auch der noch am langsten
zu erkennede Kern. Dass die als kurze Stabchen von den Zellen
aufgenommenen Bacillen in diesen wachsen und, nachdem sie
das Innere derselben unter Bildung von verschiedenen Knick-
ungen und Kriimmungen ausgefullt haben, schliesslich sprengen,
geht daraus hervor, dass man neben den freigerwordenen Bacil-
len-Spiralen (Fig. 7g) und -Biindeln zusammengefallene und
leere Zellmenbranen als letzten Rest der zerstorten Zellen findet
(Fig. 7c).*
Ganz besonders schon sind diese bacillenholtigen Zellen zu
sehen, wenn dem Praparat etwas destillirtes Wasser zugesetzt
wird. Die Zellen quellen dadurch etwas auf, ihr Inhalt wird
deutlicher und wenn sie durch die Flussigkeitsstromungen fort-
gerissen in eine rollende Bewegung versetzt werden, kann man
sich leicht die Ueberzeugung verschaffen, dass auch einzelne
Bacillen wirklich im Innern der Zelle und zwar gewohnlich dicht
neben dem Kern liegen und nicht etwa nur in die weiche Zellen-
Oberflache eingedriickt sind. Man hat schon vielfach die Ver-
muthung ausgesprochen, dass die amoboiden Zellen des Thier-
korpers, also vor Allem die weissen Blutkorperchen in derselben
Weise, wie sie den leicht nachweisbaren kiinstlich ins Blut einge-
fuhrten Farbekornchen den Eingang in ihr Protoplasma gestat-
ten, so auch die in die Blutbahn eingedrungenen Micrococcen
aufzunehmen vermogen. So viel ich weiss, ist es jedoch bis jetzt
nicht gelungen, die weder durch inre Form noch durch ihre Reac-
tionen von den Molekularkornchen dieser Zellen scharf unter-
schiedenen Micrococcen als solche mit Bestimmtheit nachzu-
weisen. Arch scheint bis jetzt viberhaupt kein volkommen
sicheres Beispiel fur das Vorkommen von schizophytenhaltigen
lebenden thierischen Zellen bekannt zu sein, und ich habe des-
wegen von den vorhin beschriebenen Zellen in (p. 3 02 ) Fig- 7 e * ne
Abbildung gegeben. Diese Beobachtung steht in sofern nicht
* Zu mehr als mittlerer Lange wachsen die Faden unter der Froschhaut nicht aus,
ich habe auch niemals Sporenentwickelung in denselben gesehen. Nach mehreren Tagen
*ird ihre Zahl geringer, die scheinen allmahlich zu zerfallen, doch habe ich bei einem
Frosche 2ehn Tage nach Transplantation der Mausemilz noch lange Faden und bacillen-
haltige Zellen gefunden.
774 Medical Classics
vereinzelt, als ich bei andern Froschen, nachdem faules ge-
trocknetes Blut unter die Riickenhaut gebracht war, dieselben
Zellen gefunden habe; aber in diesem Falle enthielten sie ganz
andere kurzgliederige Bacillen, welche meistens mit einer Dauer-
spore versehen waren (Billroth’s Helobacterien). Auch in der
frisch untersuchten Milz eines an Milzbrand gefallenen Pferdes
(die einzige, welche ich zu untersuchen Gelegenheit hatte) waren
neben sehr zahlreichen freien Stabchen grosse blasse Zellen,
meistens mit mehreren Kernen vorhanden, von denen viele eine,
bis zehn und mehr Bacillen enthielten.
IV. Aetiologie des Milzbrandes. Werfen wir nun einen Blick
zuriick auf die bis jetzt gewonnenen Thatsachen und versuchen
wir mit ihrer Hulfe die Aetiologie des Milzbrandes festzustellen,
so durfen wir uns nicht verhehlen, dass zur Construction einer
luckenlosen Aetiologie noch Manches fehlt. Vor Allem ist nicht
zu vergessen, dass sammtlich Thierexperimente an kleinen
Nagethieren angestellt sind. Es ist allerdings unwahrscheinlich,
dass die Wiederkauer, die eigentlichen Wohnthiere des uns be-
schaftigenden Parasiten, sich diesem gegeniiber sehr verschieden
von Nagethieren verhalten sollten. Aber schon bei den Impf-
versuchen besteht in sofern ein Unterschied, dass kleine Thiere
nach 24—30 Stunden, grosse erst nach mehreren Tagen sterben.
Konnten nicht vielleicht wahrend dieser langeren Zeit die Bacillen
an irgend einer Stelle des thierischen Korpers zur Sporenbildung
kommenr Oder gelangen sie uberhaupt niemals im lebenden
Korper zur Ansetzung von Sporen? Ferner sind die Fiitterungs-
versuche mit Bacillen und Sporen bei Nagethieren mit ihrem
negativen Resultat durchaus nicht massgebend fur Wiederkauer,
deren ganzer Verdauungsprozess doch wesentlich anders ist.
Einathmungsversuche mit sporenhaltigen Massen fehlen noch
ganz. Auch sind Versuche iiber das Verhalten grosserer Milz-
brandcadaver bei verschiedenen Temperaturen, in verschiedenen
Bodentiefen und Bodenarten (Thon-, Kalk-, Sandboden, trock-
ener Boden, feuchter Boden, Einfluss der Grundwassers) in
Bezug auf die Sporenbildung der Bacillen noch nicht gemacht
und es wiirde doch von hochstem praktischem Werth sein, gerade
hieruber sichere Kenntniss zu erlangen. Noch eine Menge Ein-
Untersuchungen iiber Bacterien 775
zelheiten iiber das Verhalten der Bacillen und ihrer Sporen gegen
zerstorende oder ihre Entwickelung hindernde Stoffe, iiber den
Vorgang ihrer Einwanderung in die Blut- und Lymphgefasse
miissten erforscht werden. Wenn aber auch noch manche Frage
iiber diesen bisher so rathselhaften Parasiten zu losen (p. 303)
ist, so liegt sein Lebensweg jetzt doch so weit vor uns offen, dass
wir die Aetiologie der von ihm veranlassten Krankheit wenigstens
in der Grundziigen mit voller Sicherheit feststellen kommen.
Vor der Thatsache, dass Milzbrandsubstancen, gleichviel ob
sie verhaltnissmassig frisch oder ausgefault oder getrocknet und
Jahre alt sind, nur dann Milzbrand zu erzeugen vermogen, wenn
sie entwicklungsfahige Bacillen oder Sporen des Bacillus Anthracis
enthalten, vor dieser Thatsache miissen alle Zweifel ob der Bacil-
lus Anthracis wirklich die eigentliche Ursache und das Contagium
des Milzbrandes bildet, verstummen. Die Uebertragung der
Krankheit durch feuchte Bacillen im ganz frischen Blut kommt in
der Natur wohl nur selten vor, am leichtesten noch bei Menschen,
denen beim Schlachten, Zerlegen, Abhauten von milzbrandigen
Thieren Blut oder Gewebssaft in Wunden gelangt. Haufiger
wird wahrscheinlich die Krankheit durch getrocknete Bacillen
veranlasst, welche, wie nachgewiesen wurde, ihre Wirksamkeit
einige Tage, im giinstigsten Falle gegen fiinf Wochen erhalten
konnen. Durch Insekten, an Wolle und dergleichen haftend,
namentlich mit dem Staub, konnen sie auf Wunden gelangen und
dann die Krankheit hervorrufen. Bacillenhaltige Massen, welche
in Wasser gelangen und dort stark verdiinnt werden, verlieren
sehr bald ihre Wirksamkeit und tragen zur Verbreitung des Milz-
brandes wahrscheinlich nur ausnahmsweise bei.
Die eigentliche Masse der Erkrankungen aber, welche fast
irnmer unter solchen Verhaltnissen eintritt, dass die eben genann-
ten Uebertragungsweisen ausgeschlossen werden miissen, kann
nur durch die Einwanderung von Sporen des Bacillus Anthracis
in den Thierkorper verursacht werden. Denn die Bacillen selbst
konnen sich in dauernd trocknem Zustande nur kurze Zeit
lebensfahig erhalten und vermogen deswegen sich weder im
feuchten Boden zu halten, noch den wechselnden Witterungsver-
haltnissen (Niederschlagen, Thau) Widerstand zu leisten, wahr-
Medical Classics
776
end die Sporen dagegen in kaum glaublicher Art und Weise aus-
dauern. Weder jahrelange Trockenheit, noch monatelanger
Aufenthalt in faulender Fiussigkeit, noch wiederholtes Ein-
trocknen und Anfeuchten vermag ihre Keimfahigkeit zu storen.
Wenn sich diese Sporen erst einmal gebildet haben, dann ist
hinreichend dafiir gesorgt, dass der Milzbrand auf lange Zeit in.
einer Gegend nicht erlischt. Dass aber die Moglichkeit zu ihrem
Entstehen oft genug gegeben ist, wurde friiher schon hervorge-
hoben. Ein einziger Cadaver, welcher unzweckmassig behandelt
wird, kann fast unzahlige Sporen liefern und wenn auch Mil-
lionen von diesen Sporen schliesslich zu Grunde gehen ohne zur
Keimung im Blute (p. 304) eines Thieres zu gelangen, so ist bei
ihrer grossen Zahl doch die Wahrscheinlichkeit nicht gering, dass
einige vielleicht nach langer Lagerung im Boden oder im Grund-
wasser, oder an Haaren, Hornern, Lumpen und dergleichen
angetrocknet als Staub, oder auch mit Wasser auf die Haut der
Thiere gelangen und hier direct durch eine Wunde in die Blut-
bahn eintreten, oder auch spater durch Reiben, Scheuern und
Kratzen des Thieres in kleine Hautabschilferungen eingerieben
werden. Moglicherweise dringen sie auch von den Luftwegen
oder vom Verdauungskanal aus in die Blut- oder Lympfgefasse ein.
Wenn es nun gelungen ist, die Art und Weise der Verbreitung
des Milzbrandes und die Bedingungen aufzufinden, unter denen
das Contagium sich immer wieder von Neuem erzeugt, sollte es
da nicht moglich sein, unter Beriicksichtigung jener Bedingungen
das Contagium, also den Bacillus Anthracis , in seiner Entwick-
lung zu hindern und so die Krankheit auf ein moglichst geringes
Mass zu reduciren, vielleicht sogar ganzlich auszurotten? Dass
diese Frage ein nicht geringes Interesse beansprucht, mag daraus
hervorgehen, dass nach Spinola* ein einziger preussischer Kreis
(Mannsfelder Seekreis) jahrlich fur 180,000 Mk. Schafe durch
Milzbrand verliert, dass allein im Gouvernement Nowgorod in
den Jahren 1867-1870 iiber 56,000 Pferde, Kiihe und Schafe und
ausserdem 528 Menschen an Milzbrand zu Grunde gingen.f
Die jetzt bestehenden Massregeln gegen den Milzbrand be
* Pappenheim, Sanitatspolizei Band II. p. 276.
t Grimm (Virchow’s Archiv B. 54 p. 262) citrirt nach Bollinger 1 . c. p. 469.
Untersuchungen iiber Bacterien 777
schranken sich auf Anzeigepflicht, Vergraben der Cadaver in
massig tiefen Gruben, Desinfection und Absperrung des von der
Seuche befallenen Ortes. Ganz abgesehen davon, dass er
fahrungsgemass wegen der hochst lastigen Sperrmassregeln die
wenigsten Milzbrandfalle angezeigt werden und dass der gerade
under den Schafen am meisten verbrei tete Milzbrand fast ganz
unbeachtet bleibt und vernachlassigt wird, so muss offenbar das
Eingraben der Cadaver in den feuchten Erdboden die Bildung
von Sporen und damit die Fortpflanzung des Contagiums eher
fordern als dieselbe verhindern. Bis jetzt ist es anscheinend
auch noch nirgends wo gelungen, auf diese Weise den Milzbrand
dauernd zu beseitigen. Im Gegentheil hat Oemler* seinen
Schafverlust an Milzbrand von 21% pro anno auf 2% herabge-
bracht, nachdem er das (p. 305) Verscharren aller Cadaver ohne
Ausnahme auf Feldern und Weiden auf das Strengste untersagt
hatte.
Wir miissen uns also nach anderen Mitteln umsehen, um die
Heerden von diesem Wiirgeengel zu befreien und tausende von
Menschen vor einem qualvollen Tode zu schiitzen.
Das sicherste Mittel ware, alle Substanzen, welche Bacillus An-
thracis enthalten, zu vernichten. Da es aber nicht ausfuhrbar
ist, diese Menge von Cadavern, wie sie der Milzbrand liefert,
durch Chemikalien oder Siedehitze unschadiich zu machen, oder
gar durch Verbrennen aus dem Wege zu schaffen, so miissen wir
auf dieses Radicalmittel verzichten. Wenn es aber auch nur
gelange, die Entwickelung der Bacillen zu Sporen zu verhindern
oder wenigstens auf ein Minimum zu reduciren, dann mussten
schon die Milzbrand-Erkrankungen immer mehr und mehr
abnehmen und schliesslich verschwinden.
Da die Bacillen, wie wir gesehen haben, zur Sporenbildung
Luftzufuhr, Feuchtigkeit und eine hohere Temperatur als unge-
fahr 1 5 0 nothig haben, so muss es geniigen, ihnen eine dieser
Bedingungen zu nehmen, um sie an der Weiterentwickelung zu
hindern. Die schnelle Austrocknung grosser Cadaver wiirde
besondere Apparate erfordern und selbst grossere Schwierig-
* Bollinger 1 . c. p. 453.
Medical Classics
778
keiten machen, als das Verbrennen. Dagegen konnte man ohne
erhebliche Miihe und Kosten die Milzbrand-Cadaver langere Zeit,
auch selbst im Sommer, unter 15 0 abkuhlen, ihnen gleichzeitig
den Sauerstoffzutritt beschranken und auf diese Weise die
Bacillen zum Absterben bringen. Wenn man namlich bedenkt,
dass im mittleren Europa, also namentlich in Deutschland in
einer Boden-Tiefe von 8-ioMetern eine fast constante Tempera-
tur herrscht, welche dem Jahresmittel sehr nahe Kommt, also
auf jeden Fall unter 15 0 C. bleibt, so brauchte man nur gerau-
mige Brunnen oder Gruben von dieser Tiefe anzulegen und die
Milzbrandcadaver darin zu versenken, um die Bacillen zu ver-
nichten und die Cadaver dadurch unschadlich zu machen. Je
nach der Durchschnitts-Zahl der Milzbrandfalle miissten der-
artige Gruben in geringer oder grosser Zahl fur bestimmte Be-
zirke gemacht werden. Dieselben wiirden sich in massiger
Entfernung von den Wirthschaftsgebauden befinden und natiir-
lich mit einem sicheren Verschluss zu versehen sein. Man wiirde
dadurch zugleich den nicht zu unterschatzenden Yortheil er-
langen, dass nicht, wie es jetzt gewohnlich geschieht und wie ich
aus eigener Erfahrung weiss, die vorschriftsmassig oder auch
vorschriftswidrig vergrabenen Milzbrandcadaver regelmassig von
Dieben (oft genug von denselben Leuten, (p. 306) welche sie am
Tage eingescharrt haben) des Nachts wieder herausgeholt,
zertheilt und uberall hin verschleppt werden.
Vielleicht verhindert auch der Einfluss gewisser Bodenarten
oder ein gewisser Feuchtigkeitsm angel und defer Grundwasser-
stand die Sporenentwickelung, worauf das an bestimmte Ge-
genden gebundene Vorkommen des Milzbrandes und die Ab-
nahme desselben nach ausgedehnten Meliorationen und Ent-
wasserungen hindeutet.
Der von Buhl berichtete Fall,* dass Milzbrand unter Pferden
auf dem Gestiite Neuhof bei Donauworth vollkommen aufhdrte,
als man auf den Rath v. Pettenkofer’s den Stand des Grund-
wassers durch Drainage herabgesetzt hatte, wiirde gleichfalls
hierher gehoren.
Bollinger Lap. 455.
Untersuchungen iiber Bacterien 779
Auf jeden Fall ist die Moglichkeit, die Entwickelung der Milz-
brandsporen zu verhiiten, gegeben und das grosse Interesse,
welches diese Angelegenheit beansprucht, miisste zu weiteren
Versuchen in der angegebenen Richtung auf geeigneten Ver-
suchsstationen dringend auffordern.
Eine Wahrnehmung, welche ich in hiesiger Gegend iiber das
Vorkommen des Milzbrandes gemacht habe, schliesse ich hier
noch an, weil dieselbe fur die Milzbrandprophylaxis wohl zu
beriicksichtigen ist. Es ist namlich auffallend, dass der Milz-
brand das ganze Jahr hindurch fast ohne Unterbrechung unter
den Schafen herrscht. In den grosseren Heerden fallen fast
niemals viele Schafe auf einmal, sondern gewohnlich einzelne
oder wenige in Zwischeraumen von einigen Tagen oder Wochen.
Rinder werden weit seltener und nur in grossen Pausen befallen,
so dass ofters mehrere Monate, ein halbes Jahr und noch langere
Zeit zwischen den einzelnen Fallen liegen. Bei Pferden tritt
Milzbrand hier nur ganz ausnahmsweise auf. Es scheint dem-
nach, dass das Schaf das eigentliche Wohnthier des Bacillus
Anthracis ist und dass er nur unter besonderen Verhaltnissen
gelegentlich Excursionen auf andere Thierarten macht. Fur
diese Ansicht spricht auch die Beobachtung von Leonhardt,*
dass in Bonstadt, welches sehr viel durch Milzbrand litt, derselbe
unter den Rindern fast vollkommen erlosch, nachdem man die
Schafe abgeschafft hatte, welche im Sommer massenhaft an
Milzbrand fielen. Es folgt aber daraus, dass bei alien Massre-
geln gegen die Seuche der Milzbrand unter den Schafheerden die
meiste Beachtung verdient.
V. Vergleich des Milzbrandes init anderen Infections-Krank-
heiten. Damit, dass der Milzbrand auf seine eigentlichen Ur-
sachen zuriickgefuhrt wurde, ist es gleichzeitig zum ersten Male
gelungen, (p. 307) Licht iiber die Aetiologie einer jener merk-
'viirdigen Krankheiten zu verbreiten, deren Abhangigkeit von
Bodenverhaltnissen geniigend aufzuklaren weder den Anstreng-
ungen der Forschung, noch den kiihnsten und verwickeltsten
Hypothesen bislang moglich gewesen ist. Es liegt deswegen
sehr nahe, einen Vergleich zwischen Milzbrand und den durch
ihre Verbreitungsweise ihm nahestehenden Krankheiten, vor
Allem mit Typhus und Cholera anzustellen.
* Bollinger L c. p. 453.
780 Medical Classics
Mit Typhus hat der Milzbrand Aehnlichkeit durch die Ab-
hangigkeit vom Grundwasser, durch die Vorliebe fur Niederungen,
durch das fiber das ganze Jahr vertheilte sporadische Auftreten
und das daneben eintretende Anschwellen der Erkrankungsfalle
zur Epidemie im Spatsommer. Die ersten der oben genannten
Punkte treffen auch fur die Cholera zu; in einer Hinsicht aber
stimmt das Contagium der Cholera mit dem des Milzbrandes in
so eigenthumlicher Weise zusammen, dass wohl die Annahme
eines reinen Zufalls ausgeschlossen werden muss. v. Pettenkofer
hat darauf hingewiesen, dass das Cholera-Contagium auf Schiffen,
wenn diese kein Land beruhren, meist in drei bis vier Wochen
abstirbt, nur wenn dasselbe vor dieser Zeit wieder in geeigneten
Boden gelangt, vermag sich die Krankheit weiter zu verbreiten.
Nehmen wir nun einmal an, dass der Milzbrand eine Krankheit
ware, welche in Indien heirmsch ist, und dass von dieser Krank-
heit befallene Thiere nur nach vier- bis funfwochentlicher Seefahrt
zu uns gelangen konnten, dann wurde gerade so wie bei der
Cholera eine Verschleppung auf dem Seewege nicht moglich sein,
da sich aus Mangel an feuchtem Boden keine Sporen bilden
konnten und die etwa an Gegenstanden eingetrockneten Bacillen
schon vor Beedigung der Fahrt abgestorben waren. Wiirden
wir noch ferner annehmen, dass der Milzbrand eine Krankheit
sei, die nicht durch grosse Bacillen, sondern durch andere ausser-
ordentlich kleine, an der Grenze des Sichtbaren stehende Schizo-
phyten erzeugt werde, welche nicht frei im Blute, sondern (wie
die Bacillen in der Pferdemilz) in den weissen Blutkorperchen, in
den Zellen der Lymphdriisen und der Milz versteckt, ihre dele-
tare Wirkung ausubten, dann miisste man diesen Schizophyten
eine noch viel nahere Verwandtschaft mit dem Contagium der
Cholera und des Typhus zugestehen. Keine Substanz konnte
in der That eine grossere Aehnlichkeit mit dem Contagium dieser
Krankheit besitzen, als ein derartiges Milzbrandcontagium.
Bei solchen Betrachtungen regt sich unwillkurlich die Hoffnung,
dass auch das Typhus- und Cholera-Contagium in Form von
Kugel-bacterien oder ahnlichen Schizophyten aufzufinden sein
musse. Dem (p. 3°8) stehen jedoch die erheblichsten Bedenken
Untersuchungen iiber Bacterien 781
entgegen. Vorausgesetzt namlich, dass diese Krankheiten von
einem belebten Contagium abhangen, so muss angenommen
werden, dass dasselbe unsern optischen Hiilfsmitteln schwer oder
gar nicht zuganglich ist, da viele der geiibtesten Mikroskopiker
es bis jetzt vergeblich gesucht haben. Sollte ein derartiges
Contagium noch gefunden werden, dann wiirde uns ausserdem,
da Typhus und Cholera nicht auf Thiere zu iibertragen ist, das
einzige Mittel fehlen, um uns stets von der Identitat der mo-
glicherweise in ihrer ausseren Gestalt wenig charakteristischen
Schizophyten zu iiberzeugen. Also gerade das, was die Unter-
suchungen iiber das Milzbrand-Contagium so einfach und so
sicher macht, namlich die unverkennbare Form der Bacillen
und die durch Impfung fortwahrend iiber sie ausgeiibte Controle,
wiirden fur Typhus und Cholera fehlen. Trotzdem diirfen wir
uns durch die fur manche Krankheiten vorlaufig noch uniiber-
windlich erscheinenden Hindernisse nicht abschrecken lassen,
dem Ziele, so weit als unsere jetzigen Hiilfsmittel es zulassen,
nachzustreben. Nur darf man nicht, wie bisher, mit dem
Schwierigsten beginnen. Erst muss das Naheliegende erforscht
werden, was von unseren Hiilfsmitteln noch erreicht werden kann.
Durch die hierbei gewonnenen Resultate und Untersuchungs-
methoden miissen wir uns dann den Weg zum Ferneren und
Unzuganglicheren zeigen lassen Das vorlaufig Erreichbare
auf diesem Gebiete ist die Aetiologie der infectiosen Thier-
krankheiten und derjenigen menschlichen Krankheiten, welche,
wie Diphtheritis, auf Thiere iibertragen werden konnen. Diese
Krankheiten gestatten uns, die fiir diese Untersuchungen allein
nicht mehr ausreichende Kraft des Mikroskops durch das Thier-
Experiment zu erganzen.
Nur mit Zuhulfenahme einer so gewonnenen vergleichenden
Aetiologie der Infectionskrankheiten wird es moglich sein, das
Wesen der Seuchen, welche das menschliche Geschlecht so oft
und so schwer heimsuchen, zu ergriinden und sichere Mittel zu
finden, um sie fern halten zu konnen.
^'ollstein, Grossherzogthum Posen, 27. Mai 1876.
FIGUREN-ERKLARUNG
Tafel XI.
Entwickelungsgeschichte von Bacillus
Fig. 1-7 Milzbrandbacillen {Bacillus Anlhracis )
Fig. I. Milzbrandfo« 7 fe» vom Blut eines Meerschweinchens; die
Bacillen als glashelle Stabchen, zum Theil mit beginnendor Quer-
theilung oder geknickt, a weisse, b rothe Blutkorperchen (p. 282).
Fig. 2. Milzbrandfo«’//<?» aus der Milz einer Maus, nach dreistiindiger
Cultur in einem Tropfen Humor aqueus\ in Faden auswachsend,
um das 3-8 fache verlangert, zum Theil geknickt und gekriimmt
(p. 282).
Fig. 3. Gesichtsfeld aus dem namlichen Praparat nach zehnstiindiger
Cultur; die Bacillen in lange Faden ausgewachsen, die oft zu
Bundeln um einander geschlungen sind; a in einzelnen Faden
erscheinen starker lichtbrechende Kornchen in regelmassigen
Abstanden (p. 282).
Fig. 4. Gesichtsfeld aus dem namlichen Praparat nach 24 stundiger
Cultur; a in den Faden haben sich langlich runde Sporen perl-
schnurartig in regelmassigen Abstanden entwickelt; b manche
Faden sind in Auflosung begriffen, die Sporen frei, einzeln oder
in Haufchen zusammengeballt (p. 283).
Fig. 5. Keimung der Sporen; a mit Hartnack 9 Imm. von Koch, b mit
Seibert VIII. Imm. von Cohn gezeichnet (vgl. p. 289). Die
Spore verlangert sich in ein walzenformiges Korperchen, die stark
lichtbrechende Masse bleibt an einem Pole liegen, wird kleiner,
zerfallt in 2 oder mehr Particen und ist schliesslich ganz ver-
schwunden.
Fig. 6. Darstellung der Cultur der MilzbrandArnY/eN in einem hohl-
geschliffenen, mit einem Deckglas bedeckten, vermittelst Olivenol
ringsum luftdicht abgeschlossenen und durch einen heizbaren M.
Schulze’schen Objecttisch auf Blutwarme erhitzten Objecttrager;
Naturl, Grosse. Die Bacillen befinden sich in einem Tropfen von
frischem Humor aqueus ; schon mit blossen Augen erkennt man
die von der Stelle der Aussaat in den Tropfen hineingevaicherten,
leicht flottirenden ausserst feinen Fadenmassen (p. 284).
783
784 .Medical Classics
Fig. 7. Gesichtsfeld aus der Umhullungsschicht eines unter die Riicken-
haut eines Frosches gebrachten Stiickchens von der Milz einer
milzbrandigen Maus; die Schicht besteht aus grosser kern-
haltigen Zellen a; in einzelnen Zellen sind mehrere kurze 3 etwas
geknickte oder gekrummte* zu Haufen vereinigte oder spiralig
gedrehte Bacillen (b) aufgenommen, welche in den Zellen weiter
wachsen und diese zuletzt sprengen; c zusammengefallene Zell-
membranen, g freigewordene ifoaTfewspiralen; e Blutkorperchen
des Frosches; auch unveranderte Bacillen sind sichtbar (p. 301).
Investigations of Bacteria
The Etiology of Anthrax, Based on the Ontogeny
of the Anthrax Bacillus
BY
DR. KOCH
Physician at Wollstcin
Published in Bcitragc zur Biologic dcr Pflrtnzcn, 2 : 277-310, 1877
NTRODUCTION. Ever since the finding of
bacilliform bodies in the blood of animals dead
from anthrax great efforts have been made to
prove that they are the cause of the direct
transmission of this disease and also responsible
for its sporadic appearance, and therefore the
true contagium of anthrax. Recently, Davaine, particularly,
has studied this problem and, supported by numerous experi-
ments with inoculation of fresh and dried blood containing rod-
like bodies, has declared with great certainty that these rods are
bacteria in the anthrax blood. The direct transmission of devel-
oped cases of anthrax in man and animals, although not definitely
demonstrable, he attributed, as he had discovered it, to the
spreading of bacteria, which remained viable in the dr}' state for
a long time, through air currents, insects and the like. The man-
ner of the spreading of anthrax seemed to be explained fully in
this way.
Nevertheless, these statements proposed by Davaine were
met with contradiction by various authors. Some investigators
claimed to have produced fatal anthrax after inoculation with
Medical Classics
788
bacteria-containing blood, (p. 278) without the later presence of
bacteria in the blood and, conversely, that it was possible to pro-
duce, by inoculation with this bacteria-free blood, anthrax in
which bacteria were present in the blood. Others called attention
to the fact, that anthrax does not depend on a contagium which
is disseminated above the earth’s surface, but that this disease
stands in an undoubted relationship with conditions of the soil.
How could one otherwise explain that the endemic occurrence
of anthrax is associated with a moist soil, namely, in river valleys,
swampy districts and lake regions; that, also, the number of
anthrax cases is considerably greater in wet years and are massed
chiefly into the months of August and September, in which the
curve of the heat of the soil reaches its maximum, and that as
soon as the herds of cattle are led to certain pastures and drinking
places in the anthrax districts, a greater number of affections with
this disease appears every time among the animals?
These conditions are certainly not explainable by the assump-
tion of Davaine and the insufficiency has resulted in the complete
denial by many people of the importance of the bacteria in an-
thrax.
As on several occasions I had the opportunity of examining ani-
mals that died from anthrax, I utilized these in a series of experi-
ments, which were intended to explain the above mentioned dark
points in the etiology of anthrax. In these I very soon came to
the conviction, that the Davaine theory of the method of dis-
semination of anthrax is only partly right.
It appeared that the bacilli of anthrax blood are not as resistant
by far as Davaine believed himself forced to conclude. As I will
show later, the blood, which contains only bacilli, retains its
inoculability in a dry state for only a few weeks and in the moist
state for only a few days. How could such easily perishable or-
ganisms, slumbering often during the entire winter and in moist
soil perhaps for years, form the contagium of anthrax? If the
bacteria are actually the cause of the anthrax, there remains
nothing else than to assume that as a result of a metagenesis
they may be transformed into a state insensitive to alternating
desiccation and moistening, or, what is far more probable and has
Investigations of Bacteria
been indicated by Prof. Cohn, (p. 279) that the bacteria form
spores which possess the property of growing anew into bacteria
after longer or shorter resting states.
All my further experiments were directed to discovering this
suspected developmental state of the anthrax bacillus. After
some fruitless endeavors it was possible finally to achieve this
goal and thereby to determine the true etiology of anthrax in its
characteristic features.
As the ontogenesis of the anthrax bacillus offers not only a
botanical interest, but can also throw some light upon the pres-
ently undetermined etiology of infectious diseases dependent upon
the soil, I have now undertaken, although my experiments are
not yet concluded, to publish the most important results of them.
II. Ontogenesis of the Anthrax Bacillus. According to Prof.
F. Cohn’s classification of the schizophytes,* the anthrax bacilli
belong to the species Bacillus and have been given the name Bacil-
lus anthracis, which I will subsequently use instead of the in-
clusive term Bacteria.
1. In the blood and the tissue juices of the living animal the
bacilli multiply extraordinarily rapidly in the same manner as
has been observed in various other sorts of bacteria, namely, by
elongation and transverse division.
It has by no means been possible for me to see this process
directly; however, the same may be concluded from the inocula-
tion experiments frequently done already and repeated by me in
the following manner. As a very convenient and easily obtain-
able subject for inoculation I have usually used mice. At first
I inoculated them on the ears or in the middle of the tail, but
found this method uncertain, as the animals could remove the
inoculated material by rubbing and licking; later I selected as the
site of inoculation the back of the root of the tail, where the skin
is easily movable and covered with long hairs. For this purpose,
the mouse, confined under a large glass, is grasped with a long
forceps by the tail and the latter is pulled out through a narrow
slit between the cover and the edge of the glass far enough to
enable one to make a flat transverse incision into the skin of the
Beitr. z. Biol. d. Pflanz., i, No. 3: zoz.
Medical Classics
790
back of the root of the tail after which the smallest possible drop-
let of the bacillus-containing fluid is applied to the small wound,
(p. 280) Inoculations carried out in this way, which I have
made in great numbers, have had without exception a positive
result, provided very fresh anthrax substances have been used;
and I believe, therefore, that I can consider such an inoculation
as a certain test of the life or death of the bacilli, according to the
result; a view, which has been proved to be correct by other ex-
periments to be mentioned later.
Partly, then, in order to be supplied with fresh material, and
partly also to prove whether after a definite number of generations
the bacilli undergo transition into another form, mice were inoc-
ulated several times in successive series, so that without inter-
ruption the succeeding mouse was always infected with the spleen
substance of the one that died shortly before from anthrax. The
longest of this series consisted of twenty mice, so that there were
just so many generations of the bacilli; the spleen was always
considerably swollen and filled with innumerable amounts of
hyaline rods, which showed slight differences in size, were immo-
bile, and showed no spore formation or the like. These bacilli
were also present in the blood, but were by no means as numerous
as in the spleen. In these experiments there repeatedly de-
veloped from a few bacilli, as a result of many generations, con-
siderable masses of similarly formed individuals of the sort one
sees among newly developed bacilli. There were many with a
beginning transverse division in the middle, some with a kinking
at this site, and still others hanging together at an angle, and so
another method of their multiplication than by elongation and
transverse division, after they have reached about double their
length, can hardly be assumed. According to this result, it
could scarcely be expected that a change in the form of the bacilli
could be achieved by a still longer series of inoculations, or that a
different kind of generation could be found. And at the site of
inoculation of the adjacent seriously infiltrated hypodermic
cellular tissue and in the adjacent lymph nodes only short bacilli
and those in the act of division were found in rabbits and guinea-
pigs.
Investigations of Bacteria 791
The distribution of the bacilli in the body of the inoculated ani-
mals is not always uniform. In the guinea-pig the blood con-
tained extraordinarily many bacilli, so that their number often
equalled or even exceeded that of the erythrocytes; in the blood
(p. 281) of the rabbit they were considerably less numerous, often
so rare that several microscopic fields had to be examined before a
few were found; in mice the blood always contains such a small
number of bacilli that they sometimes seem to be entirely ab-
sent.* On the other hand, one finds the bacilli all the more abun-
dant and the more certainly in the lymph nodes and the spleen
in rabbits, and in mice surprising amounts in the spleen. A few
times I have examined the marrow substance of the tibia of mice,
but found only isolated bacilli in it.
The other associated details as to the deposition of the bacilli
in the tissue of the spleen, in blood vessels, as to their accumula-
tion in the capillaries and small veins and the resulting local
edemas, vascular ruptures and escape of blood, I do not wish to
enter upon because of the purely pathologic interest of these
conditions.
It would also lead me too far to discuss the question of the true
'cause of death of animals dying from anthrax, and whether these
are killed by the carbonic acid developed by the intensive growth
of the bacilli in the blood or, what is more likely, by toxic al-
buminous bodies consumed by the parasites for their nourish-
ment.
2. In the blood of the dead animal or in other suitable nutrient
fluids the bacilli grow within certain limits of temperature and
in the presence of air to extraordinarily long, unbranched, lepto-
thrix-like threads, with the formation of numerous spores.
One is convinced most easily of the correctness of this state-
ment by the following experiment:
A drop of cattle blood serum (as fresh as possible) or of the
aqueous humor of cattle eye is placed on a slide; in this a small
* Such cases, when only the blood of animals inoculated with anthrax was examined,
probably led to the previously mentioned view, that the anthrax occurs without the
presence of bacilli in the blood, and that one can again produce anthrax by inoculation
with bacillus-free blood.
Medical Classics
79 2
piece of fresh bacillus-containing splenic substance is dropped and
the cover glass is applied over this in such a way, that the bacil-
lary mass comes to lie in the centre of the specimen. In order
to avoid drying the fluid, the slide is immediately placed in a
moist chamber and with this into the incubator.*
(p. eBa) The water content of the air in the moist chamber must
be so regulated that the fluid does not escape from under the cover
glass and the serum does not dry at the edge of the cover glass.
In the former case, the bacilli under the cover glass are washed
away and escape observation, while in the latter the dry layer of
serum walls off the air from the bacilli and any further develop-
ment is thereby prevented.
The specimens prepared in this way remain in the incubator for
15 to 20 hours at a temperature of 35 to 37 degrees C. In an
examination undertaken at that time, there are in the centre of
the specimen (Plate XI, Fig. 1) between the still intact cells of
the splenic pulp and the erythrocytes many unchanged bacilli,
but in a smaller number than in the fresh specimen. But as
soon as one leaves the centre of the specimen, one finds bacilli
that are elongated three to eight times their original length and
at the same times show some slight kinks and flexures (Fig. 1 ).
The nearer one approaches the edge of the cover glass, the longer
are the threads; these show many torsions and finally reach a
hundred and more times the length of the original bacilli (Fig.
3) . Many of these long threads have lost their uniform structure
and transparency; their content is finely granular and in places
there appear small, more refractive granules at regular distances
(Fig. 3a). Lying close to the edge, in the threads which are
located most favorably in regard to the interchange of gases in
* For the moist chambers I used flat plates filled with wet sand; a layer of filter paper
lay on the sand, and on this the specimen. The plate was covered with a glass plate.
When the layer of sand is so deep that the distance between the surface of the specimens
and the inferior surface of the glass plate is 0.5 to 1.0 cm., the specimens remain sufficiently
moist. To all who would undertake such experiments with the incubator without gas
or a regulator, I cannot highly enough recommend this method of heating. As one can
heat a large apparatus with a small flame, with a moderately large kerosene reservoir
in the lamp it is necessary only to fill the lamp about once daily and to test the height of
the flame at the proper level for the desired temperature, in order to have a constant
temperature varying between 1 to 2 degrees without special care or supervision.
Investigations of Bacteria 793
the nutrient fluid, the development has progressed the most.
These threads contain fully developed spores, which are deposited
in the form of somewhat elongated, round, (p. 283) markedly
refractive bodies at very regularly short distances in the substance
of the threads (Fig. 4a). In this form, especially when they are
much intertwined and grouped in lines winding around one an-
other, the threads make a surprising picture, which may best be
compared with that of the most delicate and artificially arranged
string of pearls.
Some of the threads are already involved in the process of dis-
solution and their former form is still indicated only by the link-
formed position of the spores held together by a mucous connect-
ing substance. Between them there occasionally lie isolated
free spores and spores conglomerated into small heaps (Fig. 4b).
In such an isolated well-prepared specimen all the transitions
from the short bacillary rods up to the long spore-bearing threads
and free spores are present and with it can be brought proof that
the latter have originated from the former. In spite of the fact
that I originally repeated this experiment several times and al-
ways obtained the same result, various doubts as to the correct-
ness of this assumption arose in my mind. How did the bacilli,
in which I heretofore observed no independent motion, come to
the edge of the specimen, while the erythrocytes remained in
the centre? Could not the long spore-bearing threads possibly
have developed at the edge of the fluid through germs having
reached there from the air? For the specimens were not pro-
tected against such a contamination from the air and, in fact, the
prettiest colonies of Micrococcus and Bacterium often prolifer-
ated in this way next to the threads in the specimen; a few times
there also appeared a type of bacillus similar to ours. All
depended, therefore, upon absolute certainty and upon not falling
into an error. Unfortunately in the past, such an error has fre-
quently been made by experienced investigators in experiments
of culturing the lowest form of organisms. As a result of these
errors, investigations in this field have in recent times come to be
somewhat discredited. I refer to the mistake of immediately
pronouncing similar forms, which develop simultaneously or
Medical Classics
794
shortly after each other in the same nutrient fluid and intermingle
with apparent transitional forms, as different developmental
stages of the same organism.
Inasmuch as the conditions for the development of the Bacillus
anthracis were known to me, namely, the nutrient fluid, the tem-
perature at which it grows and the necessity for the access of air,
I endeavored to provide these demands on the microscope table,
(p. 284) in order to be able to observe the change of the bacilli
directly.
As difficult as at first I imagined this experiment to be, so
simple it proved in reality. After many a fruitless experiment I
found the following method to be most useful:
As the source of heat I used M. Schulze’s heatable stage for
examining objects, which I heated with a kerosene lamp just as
was previously described with the incubator. The microscope
must be placed on a support in order to bring the lamp, which is
supplied with a flat kerosene reservoir made of tin, with its chim-
ney under the arm of the heatable stage. A single small flame,
standing about under the centre of the one arm, sufficed in my
apparatus to maintain the stage for days at the necessary tem-
perature. The moist, air-containing chamber was replaced by a
hollow ground glass slide covered by a cover glass. The amount
of air supplied in this way to the bacilli for their development is
very slight, but as experience teaches, sufficient for the success
of the experiment. In order to find the proper temperature for
the hollow ground glass slides of the sort used by me, I utilized
the melting point of cattle tallow, which was estimated in the
water bath fairly accurately at 40°C. A droplet of this previ-
ously-tested cattle tallow was placed on agla ss slide and this slide
in turn was placed in the cavity of the hollow slide with the tal-
low droplet directed downward; the cavity was made airtight by a
layer of Provencal oil painted all around it. It was found that
the stage had to be heated to 45°C. in order to bring the drop
under the cover glass to the melting point. For the temperature
necessary for my experiments it was sufficient to heat the stage
to such a degree that its thermometer constantly pointed to 40°C.
At the same time it became noticeable that the approach of the
Investigations of Bacteria 795
tube of the microscope, as is necessary for adjustment of an ob-
ject with a Hartnack objective lens 7 and an ocular 3, which I
used in these experiments, had a markedly cooling effect each
time and reduced the temperature in the drop by 5 to 8 degrees.
After these findings I placed a drop of fresh cattle blood serum or,
what proved better for this experiment, a drop of fresh and pure
aqueous humor of cattle eyes, on the under surface of the cover
glass. Naturally, the drop must not be too thick (p. 285) that
all its layers may not be seen with the microscope.* The
smallest possible amount of fresh bacillus-containing splenic sub-
stance was then introduced at the edge of the drop and the cover
glass was immediately placed onto the glass slide painted with the
oil. The small cavity rapidly filled with steam and the initial
evaporation of the drop was so slight, that a few bacilli dried up
only at the outermost edge; later the drop maintained its form
intact for days. The specimen prepared in this way was then
placed on the warm stage and after the currents in the warming
fluid had subsided, and some of the bacilli lying more toward the
centre of the drop had become fixed and had been drawn quickly
according to their form and position, the tube of the microscope
was screwed up in order to avoid an asymmetrical and too pro-
longed cooling of the specimen. At the following examinations
made every ten to twenty minutes, it was seen that the bacilli
at first became somewhat thicker and apparently swelled up, but
hardly changed during the first two hours. Then their growth
began. After three to four hours they had reached ten to twenty
times their former length, they began to bend, and to displace
one another or to move among themselves as in a network. After
* Among the different types of hollow ground glass slides I found the most convenient
to be one 3 mm. thick which, incidentally, is 60 mm. long and 20 mm. wide. Its upper
surface is ground lusterless; the cavity has the form of a spherical section, a diameter
of 14 mm., and a depth of 1.5 mm. Hartnack’s cover glasses, 18 mm. square and 0.15
mm. thick, may very well be fastened air tight on such slides with oil. The drop on the
under surface of the cover glass I gave a diameter of about 5 to 7 mm., so that it remains
about 3 to 5 mm. removed from the oil all around and even when the oil flows somewhat
inward under the cover glass, cannot easily reach it. In the culture experiments in the
incubator, I have found glass slides with a paraffin ring very practical. One can easily
make them in every desired size and form and use them in exactly the same way as hol-
low ground glass slides.
796 Medical Classics
a few additional hours, the individual threads were already so long
that they covered several microscopic fields; they simulated a heap
of glass threads which unite in the manner of creeping plants in the
most varying manner, sometimes in long parallel files or in ex-
tremely delicate spirally formed twisted bundles, and sometimes
in the most irregular figures of an inextricable tangle, (p. 286)
It was absolutely impossible to follow the individual thread for
its entire length.
If one observes the free end of a thread continuously for a long
time, after about 15 to 20 minutes it is easy to see a continuous
elongation. One can get an idea of the remarkable play of visible
growth of the bacilli and can obtain immediate proof of its further
development. After 10 to 15 hours the content of the strongest
and most luxuriantly grown threads appear finely granular and
very small, pale, glistening granules are soon given off. These
enlarge after several hours into the markedly refracting egg-
round spores. Gradually the threads then degenerate and
crumble at their ends. The spores become free, sink to the lower
layers of the drop according to the laws of gravity, and accumu-
late there in dense heaps. The specimen then remains in this
state unchanged for weeks. The illustrations on Plate XI
(Figs. 1-4) give the truest possible picture of the various stages
of development of the Bacillus anthracis described above.
Occasionally various kinds of bacteria appeared in large swarms
and resting colonies as unwelcome guests even in the specimens
that were prepared and treated in this manner, and disturbed the
observation of the later developmental stages of the Bacillus
anthracis. When one prepares a great number of specimens with
some care, using fresh, pure aqueous humor or blood serum, and
immediately places the splenic substance taken from the dead
animal in the incubator, one finds on repeated examinations in at
least half, more often in all the specimens, an absolutely pure cul-
ture of anthrax bacilli. If under the conditions mentioned above
the development of the bacilli does not occur at all, or if they
grow poorly and spore formation does not occur, there is some
error in the preparation of the experiment. One of the triviali-
ties that may be responsible for poor development can be seen
Investigations of Bacteria 797
from the following experience. At first some of my cultures failed
to grow because I placed all the cover glasses after their use into a
solution of carbolic acid. In spite of careful cleaning, traces of
carbolic acid, recognizable by smell, occasionally persisted on the
cover glasses. Only after I had convinced myself by control
experiments that such extremely slight (p. 287) amounts of
carbolic acid are sufficient to disturb the culture of the bacilli
and I had, accordingly, thoroughly cleaned the cover glasses by
repeated flushing, was I spared these failures. At one time I was
absolutely unable to bring the threads to spore formation; they
grew in peculiar curling, fairly large forms, but finally degener-
ated. Afterward they grew only isolated spores or no spores at
all. In vain I searched for the cause in a faulty construction of
the heating apparatus, in the nutrient fluid, or in other factors.
Finally it occurred to me that the oil used for the sealing of the
specimen smelled of volatile oils. I then prepared several speci-
mens at the same time in exactly the same manner, but used a
rancid oil for some and a perfect Provencal oil for the fastening
of the cover glass of others. The bacilli in the latter specimen
showed the most perfect spore formation but in the former the
spores appeared only sparsely. As this effect of the volatile
fatty acids, or perhaps of only a certain acid, which did not come
into direct contact with the drop containing the bacilli but
could only act upon it by a very slight amount of their gases,
seemed very remarkable, I repeated this experiment at different
times and always obtained the same result.
3. The spores of the Bacillus anthracis develop under certain
conditions (a definite temperature, nutrient fluid and access of
air) immediately from bacilli originally occurring in the blood.
That the shiny bodies formed in the long threads are in fact spores
and not some accidental products of degeneration or residua of
the degenerating bacilli can be assumed with certainty by the
analogy of the ontogenesis of other organisms in the series of
fungi and algae. Inoculation experiments to be mentioned later
with fluids which although containing only spores of -Bacillus
anthracis and no traces of bacilli or threads were yet able to
produce anthrax with the same certainty as those containing
Medical Classics
798
fresh bacilli, confirmed this assumption. But in order to gain a
complete insight into the course of life of the Bacillus anthracis,
the wisest procedure was to continue the path formerly followed.
It was important to learn in what manner the spores again under-
went transition into bacilli, whether directly or indirectly as a
zoospore living in water, (p. 288) If possible, a way had to be
found to allow the germination of the spores under conditions
which afforded a direct microscopical observation.
All efforts at producing the further development of the spores
in distilled water and well water at an ordinary temperature or at
35°C. failed. Cultures attempted in blood serum or aqueous
humor, according to the methods described above, in closed cells
and in the incubator led to incomplete results; there developed
undoubted bacilli, which grew into long threads and developed
spores; but their number was small and the transition of isolated
spores in the bacilli could not be followed in the heaps of
spores with definite certainty. Finally, I used the following pro-
cedure which led to the goal. Droplets with masses of spores
taken from specimens, which after microscopical testing con-
tained a pure culture of Bacillus anthracis and after the long
threads were completely or mostly degenerated, were placed on a
cover glass. These were too rapidly dried, partly close to the
edge and partly toward the centre of the cover glass. This drying
kept the heaps of spores together and did not allow them to be
washed away and separated by the nutrient fluid. The masses of
spores remained dry for several hours or even days; then a drop
of aqueous humor corresponding to the size of the cover glass was
placed on an ordinary glass slide (not hollow ground) and the
cover glass was laid on it in such a way that the masses of spores
were moistened by the fluid. This specimen, which was sealed
with oil, was placed in the previously described moist chamber
and with this in the incubator, which was heated to 35 degrees C.
After a half hour, the residua of the fully grown threads, still
lying here and there between the spores, began to degenerate
completely and after about one and one-half to two hours they
had disappeared.
Investigations of Bacteria 799
After three to four hours a development of the spores was al-
ready noticeable.
This development of the spores progressed most rapidly in the
heaps at the edge of the cover glass; they had already almost
completely changed into threads, while toward the centre of the
specimen all transitions from these threads into simple spores
were found. Following observations on many such specimens
the development of the spores was seen to occur in the following
manner:
(p. 289) On careful examination with greater magnifications
(for example, Hartnack immersion 9) every spore appeared in an
egg-shaped form embedded in a spherical, transparent mass which
looked like a bright, narrow ring surrounding the spores. The
spherical form was easily recognized when the spore rolled in dif-
ferent directions. The mass first lost its spherical form, became
elongated in the direction of the long axis of the spores toward
one side, and became longitudinally egg-shaped. At the same
time the spore remained lying in one pole of the small cylindrical
body. Very soon the transparent covering became longer and
thread-shaped and at the same time the spore began to lose its
strong luster. It rapidly became paler and smaller and was
broken up into several parts, until it finally disappeared entirely.
Such a heap of spores with the transitions into threads is illus-
trated in Figure 5.
Later I was often successful in growing the spores from the
bacilli in the same specimen and in the same drop of aqueous
humor, and immediately from these again a second generation
of spore-bearing threads. If only a few bacilli reached into the
drop, the spore formation was completed, as usual, after about
twenty to twenty-four hours, the nutrient material, however, was
not yet exhausted and a few hours later the spores again grew into
bacilli, and these into threads.
Especially in such specimens could the transition of the spores
into the bacilli be observed with certainty; Figure 5b was taken
from such a specimen and Prof. F. Cohn was kind enough to pre-
pare this drawing himself with the use of magnification with a
Seibert immersion lens VIII. From these simple changes in the
8oo
Medical Classics
form of the spore during its germination it is evident that it con-
sists of a markedly refractive droplet, perhaps of an oil which is
surrounded by a thin protoplasmic layer. The latter is the true
developing cell substance, while the former constitutes perhaps a
reserve substance utilized in the germination.
With this last series of investigations the circle formed by the
changes in the form of the Bacillus anthracis is closed and there
is given the complete ontogenesis of this bacillus.
In recent years the most wonderful observations and the most
contradictory views on pathogenic schizophytes have often been
published. Therefore, as I have indicated before (p. 29 o), works
of this sort have been received both by botanists and physicians
with a well justified distrust. Accordingly I again call particular
attention to the fact that my investigations are not based upon
accidental or isolated observations, but always on experiments
repeated as often as possible and with absolutely definite results.
In order to give every one who is interested in this subject an
opportunity of convincing himself without difficulty by seeing
the correctness of the results of my investigation, I have described
as accurately as possible the methods, acquired by difficult and
time-consuming experiments, according to which I have worked.
I also lay great importance on the fact, that at my request Prof.
F. Cohn, to whom I owe special thanks for his trouble, tested and
in every respect confirmed my statements regarding the ontogen-
esis of the Bacillus anthracis in a series of specimens and experi-
ments at the Pflanzenphysiologischen Institut in Breslau.
The literature on the anthrax bacillus has been available to me
only in part and I, therefore, must abstain from a complete bibliog-
raphy. I would like to mention briefly a few works which I
became acquainted with after the discovery of the ontogenesis of
the Bacillus anthracis. Bollinger* thinks that bacilli are made
up of rows of spherical bacteria, to which they occasionally degen-
erate, and that these spherical bacteria occur only in the blood,
multiply by division and, reunited in rows, may again form rods.
Accordingly, it might almost appear as if Bollinger had also seen
* Ziemssen’s Handb. der spec. Pathol, und Therap., 3; 464.
Investigations of Bacteria 801
the spore formation. But this is not the case, as he reports to
have seen only once bacilli of 0.05 mm. lengthy a size at which the
bacilli do not undergo spore formation.
In the discussion of Bollinger’s views mentioned above, F.
Cohn states that he considers the anthrax rods to be bacilli and
that by analogy of other bacilli a propagation of them by spheri-
cal permanent spores must be expected, (p. 291) This suspicion
soon became verified. The most recent publication on anthrax
bacteria by C. O. Harz, according to the reference available to
me (Allgem. med. Centralzeitung 1876, No. 33) contains only
negative results, which must lose their importance when com-
pared with my positive findings.
III. The Biology of the Anthrax Bacillus. The possibility of
developing the Bacillus anthracis into spore-bearing threads
under artificial conditions and these spores again into bacilli
naturally does not prove that occurrence of anthrax under all
all conditions must be traced to the different developmental forms
of this type of bacteria. As it does not develop further in the
living organism, as has already been shown (at present conclu-
sively only for the animal species, with which experiments have
been done), an explanation thereof can be sought only by experi-
ments on the behavior of the Bacillus anthracis under conditions
to which it is ordinarily subjected after the death of the animal
infested by it.
Not to go too much into details, I must briefly review the very
extensive series of experiments conducted along these lines.
Substances which contain anthrax bacilli may be disseminated
in the dry state or suspended in fluids. It has been known. that
they may be active for a long time in the dry state; however, the
reports on the duration of this activity vary. The following ex-
periments were carried out in order to determine the latter more
accurately:
Spleen, lymph nodes, and the blood of mice, rabbits and guinea-
pigs, immediately after being removed from the body, were dried
in a shady and airy place, in larger pieces, in smaller masses from
about the size of a pea to that of a millet seed, and in thin layers
dried on a cover glass. One or more mice were inoculated and a
802
Medical Classics
culture experiment was conducted in a paraffin cell with this
material, at first daily, later every two days after a corresponding
amount was softened in aqueous humor. The bacillary masses
dried in very thin layers, according to their thickness, lost their
inoculability after 12 to 30 hours and also the possibility of grow-
ing into long threads in the incubator. Immediately after mois-
tening them the bacilli had the same appearance as in the fresh
state, but they very soon degenerated under conditions to be
described more fully later; (p. 292) after they had lost a certain
portion of their moisture, they died. Thicker dried pieces re-
tained their inoculability and power of development for two to
three weeks. Still larger pieces retained their effectiveness for
about four to five weeks, apparently because they dried more
slowly. But I have never been able to keep freshly dried bacil-
lary masses inoculable for a longer time, although I have modified
and repeated these experiments in various ways. This is because
I depended upon Davaine’s statements and definitely believed
that I could secure freshly maintained anthrax substances for
later experiments; but I was most sadly mistaken and therefore
had to interrupt my work several times, until I finally succeeded
in securing a constantly effective inoculation material in another
way and thereby made myself independent of any accident.
I must call special attention to a phenomenon which appeared
very striking in this series of experiments, namely, that only
those dried substances which developed spore-bearing threads
in the culture experiments would produce anthrax, and vice
versa. This observation alone would be sufficient to prove that
the transmissibility of anthrax is dependent upon the presence of
viable bacilli.
Before I proceed to the experiments on anthrax fluids, I must
mention a series of culture experiments at different temperatures.
I was chiefly interested in finding the lowermost limit of tempera-
ture at which the Bacillus anthracis was still able to develop
spores capable of germinating. A number of paraffin cells 'were
implanted, in the manner previously described, with nutrient
fluid and fresh viable bacilli and then preserved at different tem-
peratures. As this experiment was conducted during the winter,
Investigations of Bacteria 803
it was easy for me to keep individual specimens cooled down to 5
degrees C. The higher temperatures (over 40 degrees C.) were
maintained with the heatable stage. In this way it was found
that the threads grow most rapidly at 35 degrees C.; even after
twenty hours at this temperature they may be supplied with the
most beautiful spores. At 30 degrees C. the spores appear some-
what later, namely, after about thirty hours. With a still lower
temperature the development of the bacilli also becomes corres-
pondingly slower. At 18 to 20 degrees (p. 293) (Cels.), namely,
the normal room temperature, they require about two and a half
to three days for the development of spores. Below 18 degrees
spore formation occurs only exceptionally, and under ia degrees
no growth of the threads is observed at all. Below 40 degrees C.
the development of bacilli is poor and seemed to me to cease at
45 degrees; however, I have not repeated the experiments with
the growth of the bacilli at the upper limits of temperature often
enough to be able to report on them very accurately (as the heat-
able stage allows the observation of only a single specimen).
I now come to the subject so extremely important in the etiol-
ogy of anthrax, namely, the behavior of the bacilli in different
fluids and under natural conditions. Because a very small
amount of blood was obtainable from the experimental animal
available to me, the mouse, and because this blood contained
very small amounts of bacilli, I used fresh cattle blood or aqueous
humor and a few times also vitreous bodies from cattle eyes. I
rubbed up fresh mouse spleen containing bacilli into these fluids,
until the amounts in the mixture approximately equalled the
blood, serous and mucous fluids of animals dead from anthrax.
Such fluids poured into a well corked glass very rapidly take on
a most penetrating putrefactive odor in the incubator. The
bacilli disappear after twenty-four hours without growing any
threads and it is then no longer possible to produce anthrax with
them. That the death of the bacilli in this case depends less
upon the influence of the developing putrefactive gases, which
cannot escape, than upon the lack of oxygen can easily be shown
by the following experiment. A drop of blood containing bacilli
is placed between an ordinary glass slide and a cover glass without
Medical Classics
804
air bubbles, is made air tight by a layer of oil painted around the
edge and is warmed on the heatable stage. When examined
under the microspectroscope, the blood shows the two bands of
oxyhemoglobin; at this time the bacilli, just as in the cell speci-
mens, begin to elongate and after about three hours reach four
to five times their original length. The oxygen is then exhausted,
the two bands disappear and between these bands one band of
reduced hemoglobin appears. From this time forward the fur-
ther growth of the bacilli also completely ceases, although (p.
294) no putrefactive bacteria can be seen as yet and the true
putrefaction has not yet begun.* In such a specimen, if it is
kept at a low temperature, one can in an excellent manner study
the changes in the bacilli in the process of dying. This process
occurs in the following manner. Fresh bacilli and those engaged
in lusty growth (excepting at the time just before the formation
of spores) always have a homogeneous transparent content and
show only very isolated articulation, indicated by angular kinks.
The first sign to be recognized in the bacilli is a clouding of the
content and a severance into shorter divisions. The bacilli
then appear more or less distinctly articulated as the extremely
fine cell membrane surrounds and holds together these parts as
in a sheath. But very soon the bacilli lose their sharp contours
and seem to consist of short, circular pieces hanging loosely to-
gether. They finally degenerate completely. From time to
time, often for days, I have observed isolated bacilli degenerated
in this manner in the most varying kinds of specimens, but have
never seen a transition of the same into micrococci or the like.
On the other hand, entirely different pictures are obtained on
repeated examinations of the bacillus-containing fluids men-
tioned, when access of oxygen is made possible, even though it is
in very small amounts, and the temperature is not reduced per-
manently below 18 degrees C. The resulting changes can be
followed very well, if about 10 to 20 gm. of the fluid in a watch
* In the unopened body of an animal dead from anthrax the bacilli elongate, but
when the cadaver is left for a long time at a temperature of 18 to 20 degrees C. they
elongate very slightly or not at all; apparently this occurs because the oxygen of the
blood after death is rapidly exhausted by oxidative processes and is not restored again.
Investigations of Bacteria 805
crystal, upon which a loosely occluding glass plate is placed,
remain for several days at room temperature. After twenty-four
hours the fluid takes on a putrefactive odor, which is usually very
penetrating after an additional twenty-four hours. Accordingly,
micrococci and bacteria are soon present in large amounts. At
the same time the Bacillus anthracis flourishes very well, as if it
were the only inhabitant of the nutrient fluid. Its threads
achieve a considerable length after twenty-four hours; (p. 295)
often after forty-eight hours, and even earlier, they have grown
spores in large amounts.* After the development of the spores
the threads degenerate and the spores sink to the floor. The
vegetation of the other schizophytes, which at times accidentally
penetrated the fluid and multiplied therein, proceeds for days in
the most luxurious manner. But gradually these also disappear,
the characteristic odor of putrefaction diminishes, a muddy
deposit finally forms and the supernatant fluid becomes poor in
formed elements and almost clear. It finally has a weak odor of
lime or cheese and no longer undergoes any change if it is pro-
tected from drying by the addition occasionally of distilled water;
the putrefactive process is completed.
When substances containing bacilli are moderately diluted with
distilled or well water, the formation of spores is not prevented;
but with greater dilution the bacilli no longer develop,! but soon
die and after thirty hours’ incubation no longer produce anthrax.
Therefore, the nutrient fluid must contain a certain amount of
salts and albumin (to be calculated more accurately) so that the
bacilli can develop spore formation.
There is no doubt that most of the cadavers of animals dead
from anthrax that were buried moderately deep during the sum-
mer, or lie on the field, in the stable, and in flaying houses, as well as
the bloody and bacillus-bearing excreta of the diseased animals
in moist soil or in stable dung, afford at least equally as favorable
conditions for the formation of spores of the Bacillus anthracis,
* Bacilli cultured in paraffin cells at the same time and under the same conditions
grew more slowly and more sparsely, possibly because of the considerably diminished
supply of oxygen.
t For example, bacilli in mouse spleen diluted with twenty times the amount;of dis-
tilled water do not grow.
8o6
Medical Classics
as is the case in the series of experiments described previously.
Through these experiments, therefore, proof was offered that the
spores of the Bacillus anthracis develop not only as a result of
artificial culture in exceptional cases, but that this parasite de-
posits its ovules in innumerable amounts every summer in the
soil, the moisture of which prevents the drying of the cavities of
the diseased animals while still living, or the nutrient fluids es-
caping from those already dead from anthrax.
We have already seen that these ovules do not change in water,
but again (p. 296) grow into bacilli in aqueous humor and blood
serum. It could be assumed from tjie very beginning that if
one or more of these spores in any way reaches the blood stream
of an animal susceptible to anthrax, a new generation of bacilli
is produced. In order to prove this assumption the following ex-
periments were carried out.
Of two covered watch crystals filled with bacillus-containing
blood serum, one was kept in a room and the other was preserved
in a cold space at 8 degrees C. From both crystals two animals
were inoculated daily. In the blood serum that was kept cold,
the bacilli became granular and articulated on the third day. Up
to that time it was effective but animals inoculated with it later
remained healthy. The inoculations with the blood serum that
was kept warm were effective both before and after the spore for-
mations in the threads of the Bacillus anthracis; even after four-
teen days it was still possible to produce anthrax with such putre-
scent blood, which contained spores of the bacilli, with the same
certainty as with fresh rod-containing spleen. The spores seemed
to be able to maintain themselves capable of germination for a
very long time in putrescent fluids just as in nonputrescent mater-
ial. For with Vitreous bodies of cattle eyes, in which bacilli from
a mouse spleen were allowed to come to spore formation at about
20 degrees C. and which had fully completed their putrefaction
after three weeks, anthrax could still be produced by inoculation
with absolute certainty even after eleven weeks. The sediment
of this fluid with completed putrefaction contained many spores
of bacilli held together by small mucous flakes, whereas on micro-
scopical examination of the almost clear fluid several fields had to
Investigations of Bacteria 80/
be searched before a single isolated spore was found. Naturally,
not the slightest trace of threads could be found any longer.
From these inoculations with the sediment rich in spores and
from those with the fluid poor in spores emanated the interesting
fact thatmice inoculated with the former material containing many
spores died after twenty-four hours, and that mice inoculated with
the latter containing less spores died after three to four
days. I also especially call attention to the fact that I have
repeated this experiment several times and always with the
same result.
Flakes containing spores from the same fluid were preserved
in an open test tube filled with well water; nevertheless these re-
mained effective in inoculations conducted with them.
(p. 297) The same spore-containing substances were dried.
After some time they were again softened with water and sub-
jected to the same procedure. They did not lose their ability to
produce anthrax as a result of the drying.
It thus becomes easily explainable why the opinions of investi-
gators regarding the effectiveness of dried anthrax blood vary so
widely; one used fresh, rapidly dried blood, which contained no
spores and which, as I have shown previously, remains effective
at the most for five weeks. Others, on the contrary, performed
the inoculation with blood that was dried slowly at room or
summer temperature and in which spores had developed. I have
a small collection of anthrax substances which were dried under
the most varying conditions and at different times and preserved
in uncorked, narrow-necked glasses. When my attention was
drawn to the importance of spores in dried anthrax masses, I
again carefully examined these pieces of dried blood, spleen, and
lymph nodes, softened with aqueous humor in glass cells, and
noted the characteristic spore-bearing threads of the Bacillus
anthracis, and their ability to produce anthrax on inoculation.
It thus became evident that the parts dried rapidly in small
pieces contained no spores and were able to develop neither
threads nor spores. Sheep spleen, however, which was dried
slowly in larger pieces in a room, and some blood tests, which were
conducted with larger amounts and had required several days for
8o8
Medical Classics
complete drying, contained numerous more-or-less free spores
and broken pieces of spore-bearing threads. All of these spore-
containing substances produced anthrax after inoculation and
often developed the most beautiful spore-bearing threads of the
Bacillus anthracis in the nutrient fluid. The length of time that
the dried spores will remain capable of germination cannot be
definitely stated at this time; this duration of time will probably
include a rather long number of years; at any rate, only recently
I have many times carried out inoculations which, without excep-
tion, produced fatal anthrax with sheep blood that was dried
almost four years ago.*
The identity of the disease produced by inoculation with an-
thrax blood and of septicemia, as well as the (p. 293) converse
relationship, has been claimed many times. In order to meet
this objection, which could possibly also be applied to my in-
oculation experiments made with putrescent anthrax substances,
I have several times inoculated mice with putrescent blood of
healthy animals, with bacillus-free putrescent aqueous humor,
and with vitreous humor of mice. These almost always remained
healthy, and only two of the twelve inoculated died a few days
after the inoculation; they had an enlarged spleen, but this, as
well as the blood, was entirely free from bacilli. In addition,
animals were inoculated with putrescent vitreous bodies, in which
a type of bacillus very similar to the Bacillus anthracis had de-
veloped spontaneously. The spores of the two types of bacillus
could not be distinguished from each other either by size or by
other appearances; only the threads of the vitreous body bacillus
were shorter and distinctly articulated. All the inoculations
with the bacilli which I found several times in the vitreous body
with their spores could not produce any anthrax. Even those
animals that were inoculated with spores cultured from bacilli
in hay infusion by Prof. F. Cohn, remained healthy. On the
other hand, I have several times inoculated masses of spores which
were cultured in glass cells and, as I have convinced myself before
* Cases of human anthrax which develop from the handling of hides, hairs, and the
like, when these articles have been dried for years, can be produced only by spore-bearing
dust particles.
Investigations of Bacteria 809
by microscopical examinations, originated from pure cultures of
the Bacillus anthracis. Every time the inoculated animal died
of anthrax. It follows, therefore, that only one type of bacillus
is able to produce this specific disease process. Other schizo-
phytes cannot produce this disease and cannot in any other man-
ner act as a disease excitant by inoculation. It might appear as
surprising that of my experimental animals inoculated with putres-
cent blood only occasionally did one die of septicemia. To
this I reply, that I did not inject the putrescent blood according
to centimeters, as is the usual custom, but I inoculated only an
infinitesimal amount of the same into the body of the animal, and
in this way, naturally, the probability of introducing the septi-
cally acting formed elements present in the blood in perhaps sparse
amount, is very much diminished.
That the spores of the Bacillus anthracis produce anthrax
when they are introduced directly into the lymph stream of the
animal body is sufficiently proved by the above mentioned ex-
periments. The spores must, therefore, become effective when
they reach wounds either in the dry state as dust particles or
suspended in fluids, no matter how small the wounds are. One
can hardly find any of our domestic animals, the skin (p. 299) of
which is not affected by some scratch wounds or excoriation of
the skin produced by chafing, rubbing and the like, and thereby
these afford easy access to the dangerous parasite. Neverthe-
less, this does not imply that the anthrax spores can penetrate
the body only in this way. In order to consider the etiology of
anthrax completely, the digestive tract and the respiratory or-
gans must also be investigated as to their power of resorption for
anthrax bacilli and their spores.
In order to see whether the anthrax contagium can penetrate
the body from the digestive tract, I first fed mice for several days
with fresh spleen from rabbits and sheep,. which had died from
anthrax. Mice are extremely voracious and in short time take
more than their body weight of masses of anthrax material, so
that a very considerable amount of bacilli passed through the
stomach and intestines of the experimental animals. But it was
impossible for me to infect them in this way. I then mixed
Medical Classics
8 io
spore-containing fluid in the food of these animals; even this they
ate without any harm; no anthrax could be produced in them
even with the feeding of larger amounts of spore-bearing blood
dried a very short time previously or years before. Rabbits that
were fed spore-containing masses at various times also remained
healthy. Accordingly, an infection from the intestinal canal
• does not seem possible in these two species of animals.
Up to the present time I cannot say anything in regard to the
behavior of spores reaching the respiratory organs with dust, as
it has not been possible for me to conduct experiments on this
subject.
I also add a few series of experiments and obervations, which
have no direct relationship with the etiology of anthrax, but are
still interesting enough to be reported.
The experiment made by Brauell, of inoculation with both the
bacillus-containing blood of pregnant animals and with the bacil-
lus-free blood of the fetus, I have repeated on a pregnant guinea-
pig and two pregnant mice. The result was the same as in
Brauell’s experiment; the animals inoculated with the maternal
blood died from anthrax, while those inoculated with fetal blood
remained healthy. In order to see how soon after the inoculation
the first bacilli can be found in the blood or in the spleen of the
inoculated animal, nine mice were inoculated at the same time.
After two, four, six, eight, ten, twelve, (p. 300) fourteen and six-
teen hours, one of these mice was killed each time with chloro-
form and the blood as well as the spleen were immediately exam-
ined. No bacilli were found in the first six animals. Only in
the mouse killed fourteen hours after the inoculation were isolated
bacilli found in the spleen. In the mouse which had lived sixteen
hours more bacilli were found and the spleen was enlarged. The
last mouse died after seventeen hours with the usual characteristic
symptoms; its spleen was considerably enlarged and completely
filled with dense masses of bacilli. The penetration of the bacilli
into the blood stream, therefore, seems to progress slowly, but
after they have once reached there and have gained a firm footing
in their true home, they multiply in the most luxurious manner.
Besides the mice, I have also conducted experiments on rabbits
Investigations of Bacteria 8n
and guinea-pigs, two dogs, one partridge and one sparrow. Al-
though I inoculated these animals repeatedly with very fresh
material, I have as yet not been able to infect them with anthrax.
Frogs are also entirely resistant to inoculations with Bacillus
anthracis or its spores. As I implanted larger pieces of spleen
from mice dead from anthrax under the skin of the back in several
frogs, and killed and examined the animals after forty-eight hours,
the following noteworthy finding was made. The blood of the
frogs was entirely free from bacilli. The mouse spleen was
slightly adherent to its surroundings and instead of its dark
brownish-red color it had assumed a more light grayish-red color.
On microscopical examination, unchanged bacilli in large amounts
were bound in the centre, but in the outer layers many bacilli
were found which had become thicker and more elongated. Be-
tween these were found peculiar structures in large number,
namely, more or less regular, spirally formed, tortuous bacilli,
which were partly free and partly surrounded by a very thin-
walled capsule. The explanation for this unusual form of the
bacilli is easily to be found when one examines the almost gelat-
inous outermost surrounding layer of the spleen, apparently
excreted by the skin of the frog (Fig. 7). This layer consists of
large cells embedded in a structureless viscous ground substance,
which almost reach the size of frog’s blood corpuscles (Fig. 7a).
In spite of their size these are very pale and delicate, have a very
distinct nucleus with nucleoli and contain many very small
(p. 301) granules engaged in the most lively molecular motion.
In most of these cells there were short straight bacilli, in others
somewhat curved, cracked bacilli, united in heaps and bundles
and, preferably, twisted spirally (Fig. 7b). As soon as the cells
harbor several bacilli, the molecular granules in them seem to be
enlarged, but if the bacillary proliferation in them predominates,
these granules disappear and, finally, also the nucleus which re-
mains recognizable the longest. That the bacilli taken up by the
cells as short rods grow in them and after they have filled the in-
terior by the formation of various kinkings and curvatures finally
rupture them, is evidenced by the fact, that in addition to the re-
leased bacillary spirals (Fig. Jg) and bundles, degenerated and
8 12 Medical Classics
empty cell membranes are found as the last residua of the de-
stroyed cells (Fig. 7c).*
These bacillus-containing cells are especially beautifully seen
if some distilled water is added to the specimen. As a result the
cells swell up to some extent, their content becomes more dis-
tinct and when they are set in a rolling motion by being torn away
by fluid currents, one can easily be convinced that isolated bacilli
also actually lie in the interior of the cells and usually close to the
nucleus and are not merely compressed into the soft cell surface.
The suspicion has been expressed many times, that the amoeboid
cells of the animal body may also take up the micrococci that
have entered the blood circulation in the same way the white
blood cells in an easily demonstrable manner allow pigment
granules, artificially introduced into the blood, access into the
interior of their protoplasm. As far as I know, up to the present
time it has not been possible to differentiate sharply the micro-
cocci from the molecular granules of these cells either by their
form or by their reactions. Up to the present time any ab-
solutely certain example of the occurrence of schizophyte-con-
taining living animal cells does not seem to be known, (p. 302)
This observation is not an isolated one insofar as I found the
same cells in other frogs after putrid dried blood was introduced
under the skin of the back; but in this case they contained en-
tirely different shortly geniculated bacilli, which were mostly
supplied with a permanent spore (Billroth’s heliobacteria).
There were also, in addition to numerous free rods, large pale
cells in the freshly examined spleen of a horse dead from anthrax
(the only one that I had occasion to examine). Most of these
cells contained several nuclei and many contained one to ten and
more bacilli.
IV, . The Etiology of Anthrax. If we review the facts learned
up to the present time and if we endeavor to determine the etiol-
ogy of anthrax with their aid, we must not conceal from our view
* The threads under the frog’s skin do not grow longer than medium length and I
have never observed the development of spores in them. After several days their num-
ber diminishes and they seem to degenerate gradually, but in one frog I have still found
long threads and bacilli -containing cells ten days after the transplantation of mouse
spleen.
Investigations of Bacteria 813
the fact that much is still lacking for an unbroken construction of
the etiology. One must not forget, particularly, that all of the
animal experiments were conducted on small rodents. It is
certainly improbable that the ruminants, the true hosts of the
parasite with which we are concerned, should behave very differ-
ently from rodents. But there is a difference in the inoculation
experiments that small animals die after twenty-four to thirty
hours, and large ones only after several days. Could not pos-
sibly the bacilli come to spore formation at some site of the ani-
mal body during this longer period of time? Or do they never
reach spore formation in the living body? Furthermore, the
feeding experiments with bacilli and spores in rodents with their
negative results are absolutely not decisive for ruminants, the
entire digestive process of which is essentially different. In-
halation experiments with spore-bearing masses are still entirely
missing. Nor have experiments on the behavior of large anthrax
cadavers been made at different temperatures, at different depths
of soil and types of soil (argillaceous, chalky, and sandy soil,
dry soil, moist soil, and the influence of ground water) in regard
to spore formation of the bacilli. It would be of the greatest
practical importance to gain definite knowledge in this respect.
A number of details regarding the behavior of the bacilli and their
spores towards substances that destroy them or hinder their
development and regarding the process of their penetration into
the blood and lymph vessels would have to be investigated. But
even though many a question on the parasites, so puzzling up to
the present time has to be answered, (p. 303) its ways of life are
open to us to such an extent, that we can definitely determine the
etiology of the disease produced by it, at least in the fundamental
principles.
Since anthrax substances, regardless of their being relatively
fresh, putrescent, or dried or years old, can produce anthrax
when these substances contain either bacilli capable of developing
or spores of the Bacillus anthracis, all doubts as to the Bacillus
anthracis constituting the actual cause and the contagium of
anthrax must be silenced. The transmission of the disease by
moist bacilli in very fresh blood rarely occurs in nature, but most
8 14 Medical Classics
readily in persons, in whom blood or tissue juices gain access to
wounds in the act of killing, cutting, and skinning of animals in-
fected with anthrax. Probably the disease is produced more
often by dried bacilli which, as has been shown, may retain their
effectiveness for a few days, and in favorable cases, for five weeks.
When attached to insects, to wool, and the like, together with
dust, they may gain access to wounds and then produce the dis-
ease. Bacillus-containing masses, which fall into water and are
markedly diluted there, very soon lose their effectiveness and
probably lead to dissemination of anthrax only exceptionally.
The great mass of the infections, however, which almost always
develop under such conditions that the above mentioned methods
of transmission must be excluded, can be produced only by the
penetration of spores of the Bacillus anthracis into the animal
body. For the bacilli can maintain themselves viable in a con-
tinued dried state only for a short time and can offer resistance
neither to moist soil nor to the changing conditions of weather
(precipitations and dew). But the spores survive in a hardly
believable manner and way. Neither years of dryness, nor exist-
ence in a putrescent fluid for months, nor repeated drying and
moistening, can destroy their power of germination. When
these spores have once formed, there is ample reason for the an-
thrax not disappearing for a long time in a certain region. It
has already been shown that their development is often made
possible. A single cadaver, which is handled improperly, can
furnish almost innumerable spores and even though millions of
these spores degenerate without reaching germination in the
blood (p. 304) of an animal, still, because of their great number,
the probability is not slight that a few may reach the skin of the
animal after a long stay in the soil or in ground water, or on hairs,
horns, rags and the like, dried as dust, or may reach the skin of
the animal with water and enter the blood circulation directly
through a wound. Even later these spores may enter into small
abrasions of the skin by rubbing, chafing and scratching of the
animal. Possibly they also penetrate into the blood or lymph
vessels by way of the air passages or the digestive canal.
If, then, it has been possible to discover the manner of the dis-
Investigations of Bacteria 815
semination of anthrax and the conditions under which the con-
tagium constantly renews itself de jjovo, should it not then be
possible, in consideration of these conditions, to hinder the con-
tagium, namely, the Bacillus anthracis, in its development and
so reduce the sickness to the smallest possible incidence and,
perhaps, even exterminate it entirely? That this question de-
mands not a little interest, may be seen from the fact that, ac-
cording to Spinola,* a single Prussian District (Mannsfelder
Seekreis) yearly loses 1 80,000 Marks worth of sheep through an-
thrax, and that during the years 1867 to 1870 over 56,000 horses,
cows and sheep and, besides, 528 persons, lost their lives from
anthrax in the Novgorod Government alone.f
The present measures against anthrax are limited to the obliga-
tion of notifying the authorities, the burial of the cadavers in
moderately deep pits, disinfection, and quarantine of the town
affected by the plague. Entirely aside from the fact that we
know by experience that only a small number of cases of anthrax
is reported because of the extremely annoying rules of quarantine
and that in the case of sheep the most widely disseminated an-
thrax remains almost completely unnoticed and neglected, the
burial of the cadaver in the moist soil must, apparently, rather
favor the formation of spores and thereby the propagation of
the contagium than prevent it. Up to the present time the con-
tinued prevention of anthrax in this manner apparently has not
been successful anywhere. On the other hand, Oemleri reduced
his loss of sheep from anthrax from 21 per cent per year to 2 per
cent, after he had (p. 305) strictly forbidden the burial of all
cadavers, without exception, in fields and pasture grounds.
We must, therefore, seek other measures in order to free the
herds from this destroyer and to protect thousands of persons
from an agonizing death.
The most certain way would be to destroy all substances that
contain the Bacillus anthracis. But as it is impossible to carry
this out, namely, to make inocuous this amount of cadavers, such
* Pappenheim, Sanitatspolizei, 2: 276.
t Grimm (Virchow’s Archiv., 54: 262) dted from Bollinger, Ibid., page 4 ^ 9 *
t Bollinger, Ibid., page 4 53.
816 Medical Classics
as anthrax provides, by chemicals or boiling heat, or even to do
away with them by burning, we must abandon this radical meas-
ure. If it would only be possible to hinder the bacilli from de-
veloping spores or, at least, reduce this to a minimum, the infec-
tions with anthrax would constantly diminish in number and
finally disappear.
Because the bacilli, as we have seen, require the access of air,
moisture and a higher temperature of about 15 degrees C. for
the formation of spores, it must suffice to deprive them of one of
these conditions in order to prevent them from further develop-
ment. The rapid drying of large cadavers would require special
apparatus and itself would cause difficulties greater than burning.
Instead of this, one could, without much trouble and cost, cool
the anthrax cadaver for a considerable time, even in the summer
time, below 15 degrees, at the same time limit the access of oxy-
gen and in this way cause the bacilli to die. Particularly, if one
considers that in Middle Europe, namely in Germany, an almost
constant temperature prevails at an 8 to 10 meter depth of the
soil, which very closely approaches the year’s average and hence
in every case remains below 15 degrees C., it would be necessary
only to dig spacious wells or pits of this depth and to sink the
anthrax cadavers in them to destroy the bacilli and thereby make
the cadaver inocuous. Such pits would have to be dug in certain
districts in smaller or greater number according to the average
number of cases of anthrax. These pits would be located at a
moderate distance from the farm buildings and, naturally, sup-
plied with a secure enclosure. In this way one would at the
same time have an advantage which is not to be undervalued
that the cadaver would not be recovered during the night, cut
up, and disseminated all around. As usually happens at present
and as I know from my own experience, the anthrax cadavers
buried according to regulations or even against them are regu-
larly stolen by thieves (often enough by the same people (p. 306)
as had buried them during the day).
It is also possible that the influence of certain types of soil or a
certain lack of moisture and of a deep ground water prevents the
development of spores. This points to the occurrence of anthrax
Investigations of Bacteria 817
in certain districts and its subsidence after extensive improve-
ments and drainages.
The case reported by Buhl,* in which the anthrax among horses
disappeared completely in the stud Neuhof at Donauworth when,
at the advice of Counsellor von Pettenkofer the depth of the
ground water was lowered by drainage, would likewise fall in
this category.
At any rate, there is the possibility of preventing the develop-
ment of anthrax spores. The great interest that this matter
demands should urgently lead to further attempts in the direction
mentioned at suitable experimental stations.
I also add an observation, which I have made in this region on
the occurrence of anthrax, because it is well worthy of considera-
tion in the prophylaxis of anthrax. It is indeed striking that
anthrax prevails through the whole year among sheep almost
without interruption. In the larger herds many sheep are almost
never affected at one time, but usually isolated ones, and often at
great intervals of time, so that several months, half a year or a
longer time, intervene between the individual cases. In this
region anthrax occurs exceptionally among horses. It appears,
therefore, that the sheep is the true host of the Bacillus anthracis
and that only under exceptional circumstances does it occasion-
ally affect other species of animals. This view is supported by
the observation of Leonhardt,f that in Bonstadt, which suffered
much from anthrax, the latter almost completely disappeared
among the cattle, after the sheep that were infected by anthrax
in greater numbers during the summer had been removed. This
leads to the conclusion, that in all measures against this pesti-
lence, anthrax deserves the greatest consideration among the
herds of sheep.
V. The Comparison of Anthrax with Other Diseases. Owing
to the fact that anthrax has been traced to its true causes, it has
been possible for the first time to (p. 307) shed light on the etiology
of those remarkable diseases, which depend on conditions of the
soil. Up to the present time it has not been possible to explain
* Bollinger, Ibid., page 455.
f Bollinger, Ibid., p. 453.
Medical Classics
8 1 8
these sufficiently either by the application of investigation or
the boldest complicated hypotheses. Therefore it is very im-
portant to make a comparison between anthrax and the diseases
closely allied to it by its method of dissemination, particularly
with typhoid fever and cholera.
Anthrax resembles typhoid fever in its dependence upon ground
water, its preference for lowlands, its sporadic appearance
throughout the entire year, and the associated increase in the
number of cases to an epidemic in the late summer. The first
of the above mentioned points applies also to cholera; but in one
respect the contagium of cholera in such a peculiar manner cor-
responds with that of anthrax that the assumption of a pure acci-
dent must be excluded. Von Pettenkofer has called attention
to the fact, that on ships the contagium of cholera, when these
do not touch land, usually dies out in three to four weeks, and
only when it reaches suitable soil before this time, can the
disease spread any further. Let us assume, for example, that
anthrax is a disease that is indigenous in India, and that
animals infected with this disease could reach us only after a four
to five weeks’ sea trip. Then, just as in the case of cholera, a
dissemination on the sea voyage could not be possible, as no
spores could develop because of the lack of moist soil. The
bacilli possibly dried on objects would have died off before the
end of the trip. If we further assume that anthrax is a disease
which is not produced by large bacilli, but by other extraordi-
narily small schizophytes at the limit of visibility, which would
exert their deleterious effect not freely in the blood, but (like the
bacilli in the horse spleen) secretly in the white blood cells, in
the cells of the lymph nodes, and in the spleen, then we would
have to admit a still much closer relationship with the contagium
of cholera and typhoid fever. As a matter of fact, no substance
would have a greater similarity to the contagium of this disease
than such a contagium of anthrax.
With such observations there arises the hope that the typhoid
and the cholera contagium will also be found in the form of spheri-
cal bacteria or similar schizophytes. (p. 308) But the most seri-
ous doubts oppose this hope. Provided that these diseases
depend upon a visible contagium, it must be assumed that it is not
Investigations of Bacteria 819
visible, or only so with difficulty, with our optical aids, as many
of the experienced microscopists have until now looked for it in
vain. Should such a contagium be found we would then still
lack the one means, as typhoid fever and cholera cannot be trans-
mitted to animals, of convincing ourselves of the identity of the
schizophytes. Their outer forms have so little that is characteris-
tic, that which makes the investigations on the contagium of an-
thrax so simple and so certain, namely, the unmistakable form of
the bacilli and the control carried on by inoculation, would be
lacking for typhoid fever and cholera. Nevertheless, we must
not be deterred by the obstacles which at present seem indomit-
able from striving for the goal, so far as our present aids allow.
But one must not begin, as heretofore, with the most difficult.
At first, only the obvious, which can be reached with our aids,
should be investigated.
We must allow the way to the more remote and inaccessible
findings to be shown to us by the results and methods of investiga-
tion gained in this way. The provisional attainment in this
field is the etiology of the infectious diseases of animals and of
human diseases which, like diphtheria, can be transmitted to
animals. These diseases give us the opportunity of supplement-
ing the microscope with the animal experiment since that instru-
ment no longer has sufficient power for these investigations.
Only with the aid of such an acquired comparative etiology of
the infectious diseases will it be possible to fathom the nature of
the epidemic diseases which affect the human race frequently
and severely, and to find sure remedies to control them.
Wollstein, Grand Ducy of Posen, May 27, 1876.
EXPLANATION OF ILLUSTRATIONS
Plate XI
Ontogenesis of the Bacillus
Figs. 1-7 Anthrax Bacilli (Bacillus Anthracis)
Fig. 1. Anthrax bacilli from the blood of a guinea-pig; the bacilli as
transparent rods, some with beginning transverse division or
kinked, (a) white, (b) red blood cells.
820 Medical Classics
Fig- 2. Anthrax bacilli from the spleen of a mouse, after 3 hours'
culture in a drop of aqueous humor; growing from threads, elon-
gated 3 to 8 times, some kinked and curved.
Fig. 3. Microscopical field from the same specimen after 10 hours'
culture; the bacilli grown into long threads, which are often wound
around one another in bundles; (a) more markedly transparent gran-
ules appear in some threads at regular distances.
Fig. 4. Microscopical field from the same specimen after 24 hours'
culture; (a) longitudinally round spores have developed in the
threads like a string of pearls at regular distances; (b) some threads
are in the act of dissolving, the spores free, isolated, or conglom-
erated in heaps.
Fig. 5. Germination of the spores; (a) with Hartnack Immersion
9 drawn by Koch, (b) with Seibert Immersion VIII drawn by
Cohn. The spore elongates into a cylindriform body, the mark-
edly refractive mass remains at one pole, becomes smaller, breaks
up into 2 or more parts, and finally disappears entirely.
Fig. 6. Representation of the culture of anthrax bacilli in a hollow
ground glass slide, covered with a cover glass, closed air tight by
means of olive oil painted all around and warmed by means of an
M. Schulze stage to blood heat; natural size. The bacilli are
located in a drop of fresh aqueous humor; even with the naked
eye one recognizes the lightly floating extremely delicate masses
of threads, proliferated into the drop from the site of the dis-
semination.
Fig. 7. Microscopical field from the surrounding layer of a small piece
from the spleen of a mouse dead from anthrax introduced under
the skin of the back of a frog; this layer consists of large, nucle-
ated cells (a); isolated cells have taken up numerous small, some-
what kinked or curved bacilli grouped into heaps or twisted
spirally (b); which continue to grow in the cells and, finally,
rupture them; (c) degenerated cell membranes, (g) liberated
spirals of bacilli; (e) blood corpuscles of the frog; unchanged
bacilli are also visible.
Figures 1 to 7 are drawn from anthrax bacilli (Bacillus anthracis)
by Dr. Koch. Magnification of Figs. 1 to 7 is 650 (drawn with Hart-
nack immersion IX, of Fig. cb i6co (drawn with Seibert immersion
VIII).
I. Die Aetiologie der Tuberculose
VON
DR. ROBERT KOCH
Regieruttgsralh im Kaiserl, Gcsundheitsamt
(Nach einem in der physiologischen Gesellschaft zu Berlin am 24. Marz cr. gehaltenen
Vortrage) Berliner Klinische Wochenschrift,- 19: 221-230, 1882
IE von Villemin gemachte Entdeckung, dass die
Tuberculose auf Thiere iibertragbar ist, hat
bekanntlich vielfache Bestatigung, aber nuch
anscheinend wohlbegriindeten Widerspruch ge-
funden, so dass es bis vor wenigen Jahren
unentschieden bleiben musste, ob die Tubercu-
lose eine Infectionskrankheit sei oder nicht. Seitdem haben
aber die zuerst von Cohnheim und Salomonsen, spater von
Baumgarten ausgefuhrten Impfungen in die vordere Augen-
kammer, ferner die Inhalationsversuche von Tappeiner und
Anderen die Uebertragbarkeit der Tuberculose gegen jeden
Zweifel sicher gestellt und es muss ihr in Zukunft ein Platz unter
den Infectionskrankheiten angewiesen werden.
Wenn die Zahl der Opfer, welch e eine Krankheit fordert, als
Massstab fur ihre Bedeutung zu gelten hat, dann miissen alle
Krankheiten, namentlich aber die gefurchtetsten Infections-
krankheiten, Pest, Cholera u. s. w. weit hinter der Tuberculose
zuruckstehen. Die Statistik lehrt, dass \ aller Menschen an
Tuberculose stirbt und dass, wenn nur die mittleren productiven
Altersklassen in Betracht kommen, die Tuberculose ein Drittel
derselben und oft mehr dahinrafft. Die offentliche Gesundheits-
pflege hat also Grand genug, ihre Aufmerksamkeit einer so
822 Medical Classics
morderischen Krankheit zu widmen, ganz abgesehen davon,
dass noch andere Verhaltnisse, von denen nur die Beziehungen
der Tuberculose zur Perlsucht erwahnt werden sollen, das Inter-
esse der Gesundheitspflege in x^nspruch nehmen.
Da es nun zu den Aufgaben des Gesundheitsamtes gehort,
die Infectionskrankheiten vom Standpunkte der Gesundheits-
pflege aus, also in erster Linie in Bezug auf ihre Aetiologie, zum
Gegenstand von Ermittelungsarbeiten zu machen, so erschien
es als eine dringende Pflicht, von Allem liber die Tuberculose
eingehende Untersuchungen anzustellen.
Das Wesen der Tuberculose zu ergriinden, ist schon wieder-
holt versucht, aber bis jetzt ohne Erfolg. Die zum Nachweis
der pathogenen Microorganismen so vielfach bewahrten Far-
bungsmethoden haben dieser Krankheit gegenliber im Stich
gelassen und die zum Zwecke der Isolirung und Zlichtung des
Tuberkel- Virus angestellten Versuche konnten bis jetzt nicht
als gelungen angesehen werden, so dass Cohnheim in der soeben
erschienenen neuesten Auflage seiner Vorlesungen liber allge-
meine Pathologie „den directen Nachweis des tuberculosen Virus
als ein bis heute noch ungelostes Problem'* bezeichnen musste.
Bei meinen Untersuchungen iiber die Tuberculose habe ich
mich anfangs auch der bekannten Methoden bedient, ohne da-
mit eine Aufklarung liber das Wesen der Krankheit zu erlangen.
Aber durch einige gelegentliche Beobachtungen wurde ich dann
veranlasst, diese Methoden zu verlassen und andere Wege ein-
zuschlagen, die schliesslich auch zu positiven Resultaten flihrten.
Das Ziel der Untersuchung musste zunachst auf den Nach-
weis von irgend welchen, dem Korper fremdartigen, parasitischen
Gebilden gerichtet sein, die moglicherweise als Krankheitsur-
sache gedeutet werden konnten. Dieser Nachweis gelang auch
in der That durch ein bestimmtes Farbungsverfahren, mit Hiilfe
dessen in alien tuberculos veranderten Organen characteristische,
bis dahin nicht bekannte Bacterien zu finden waren. Es wlirde
zu weit fiihren, den Weg, auf welchem ich zu diesem neuen Ver-
fahren gelangte, zu schildern und ich will deswegen sofort zur
Beschreibung desselben iibergehen.
Die Untersuchungsobjecte werden in der bekannten, fur
Die Aetiologie der Tuberculose 823
Untersuchungen auf pathogene Bacterien ublichen Weise, vor-
bereitet und entweder auf dem Deckglas ausgebreitet, getrocknet
und erhitzt, oder nach Erhartung in Alkohol in Schnitte zerlegt.
Die Deckglaschen oder Schnitte gelangen in eine Farblosung
von folgender Zusammensetzung. 200 Gem. destillirten Wassers
werden mit 1 Can. einer concentrirten alcoholischen Methylen-
blau-Losung vermischt, umgeschiittelt und erhalten dann unter
wiederholtem Schiitteln noch einen Zusatz von 0,2 Ccm. einer
10% Kalilauge. Diese Mischung darf selbst nach tagelangem
Stehen keinen Niederschlag geben. Die zu farbenden Objecte
bleiben in derselben 20 bis 24 Stunden. Durch Erwarmen der
Farblosung auf 40°C. im Wasserbade kann diese Zeit auf § bis 1
Stunde abgekiirzt werden. Die Deckglaschen werden hierauf
mit einer concentrirten wassrigen Losung von Vesuvin, welche
vor jedesmaligem Gebrauche zu filtriren ist, iibergossen und nach
ein bis zwei Minuten mit destillirtem Wasser abgespiilt. Wenn
die Deckglaschen aus dem Methylenblau kommen, sieht die
ihnen anhaftende Schicht dunkelblau aus und ist stark (p. 222)
iiberfarbt, durch die Behandlung mit dem Vesuvin geht die
blaue Farbe derselben verloren und sie erscheint schwach braun
gefarbt. Unter dem Microscop zeigen sich nun alle Bestand-
theile thierischer Gewebe, namentlich die Zellkerne und deren
Zerfallsproducte braun, die Tuberkelbacterien dagegen schon
blau gefarbt. Auch alle anderen bis jetzt von mir darauf hin
untersuchten Bacterien, mit Ausnahme der Leprabacillen, nehmen
bei diesem Farbungsverfahren eine braune Farbe an. Der
Farbencontrast zwischen dem braun gefarbten Gewebe und den
blauen Tuberkelbacterien ist so auffallend, dass letztere, welche
oft nur in sehr geringer Zahl vorhanden sind, trotzdem mit der
grossten Sicherheit aufzufinden und als solche zu erkennen sind.
Ganz ahnlich sind die Schnitte zu behandeln. Sie werden aus
der Methylenblau-Losung in die filtrirte Vesuvinlosunggebracht,
bleiben darin 15 bis 20 Minuten und werden dann in destillirtem
Wasser so lange gespiilt, bis die blaue Farbe geschwunden und
eine mehr oder weniger stark braune Tinction zuriickgeblieben
ist. Hiernach entwassert man sie mit Alkohol, hellt sie in
Nelkenol auf und kann sie sofort in dieser Fliissigkeit micro-
824 Medical Classics
scopisch untersuchen oder auch schliesslich in Canada-balsam
einlegen, In diesen Praparaten erscheinen ebenfalls die Ge-
websbestandtheile braun und die Tuberkelbacterien lebhaft blau
gefarbt.
Uebrigens sind die Bacterien nicht etwa ausschliesslich mit
Methylenblau zu farben, sondern sie nehmen mit Ausnahme
von braunen Farbstoffen auch andere Ainlinfarben unter der
gleichzeitigen Einwirkung von Alkalien auf, doch falltdie Farbung
bei Weitem nicht so schon aus wie mit Methylenblau. Ferner
kann bei dem angegebenen Farbungsverfahren die Kalilosung
durch Natron oder Ammoniak ersetzt werden, woraus zu schlies-
sen ist, dass nicht etwa dem Kali an sich dabei eine wesentliche
Rolle zufallt, sondern dass es nur auf die stark alkalische Be-
schaffenheit der Losung ankommt. Dafiir spricht auch, dass
durch einen noch starkeren Kalizusatz die Bacterien noch an
Stellen gefarbt werden konnen, wo sie mit einer weniger kali-
haltigen Losung nicht mehr zum Vorschein kommen. Doch
schrumpfen die Gewebstheile des Schnittpraparates und ver-
andern sich unter dem Einfluss starkerer Kalilosungen so sehr,
dass letztere nur ausnahmsweise von Vortheil sein werden.
Die durch dieses Verfahren sichtbar gemachten Bacterien
zeigen ein in mancher Beziehung eigenthiimliches Verhalten.
Sie haben eine stabchenformige Gestalt und gehoren also zur
Gruppe der Bacillen. Sie sind sehr diinn und ein viertel bis halb
so lang als der Durchmesser eines rothen Blutkorperchens
betragt, mitunter konnen sie auch eine grossere Lange, bis zum
vollen Durchmesser eines Blutkorperchens, erreichen. Sie be-
sitzen in Bezug auf Gestalt und Grosse eine auffallende Aehn-
lichkeit mit den Leprabacillen. Doch unterscheiden sich letztere
von ihnen dadurch, dass sie ein wenig schlanker und an den
Enden zugespitzt erscheinen. Auch nehmen die Leprabacillen
bei dem Weigert’schen Kern farbungsverfahren den Farbstoff an,
was die Tuberkelbacillen nicht thun. An alien den Punkten,
wo der tuberculose Process in frischem Entstehen und in schnel-
lem Fortschreiten begriffen ist, sind die Bacillen in grosser
Menge vorhanden; sie bilden dann gewohnlich dicht zusammen-
gedrangte und oft biindelartig angeordnete kleine Gruppen,
Die Aetiologie der Tuberculose 825
welche vielfach im Innern von Zellen liegen und stellenweise
eben solche Bilder geben, wie die in Zellen angehauften Lepra-
bacillen. Daneben fin den sich aber auch zahlreiche freie Ba-
cillen. Namentlich am Rande von grosseren kasigen Herden
kommen fast nur Schaaren von Bacillen vor, die nicht in Zellen
eingeschlossen sind.
Sobald der Hohepunkt der Tuberkeleruption iiberschritten
ist, werden die Bacillen seltener, finden sich nur noch in kleinen
Gruppen oder ganz vereinzelt am Rande des Tuberkelherdes
neben schwach gefarbten und mit unter kaum noch erkennbaren
Bacillen, welche vermuthlich im Absterben begriffen oder schon
abgestorben sind. Schliesslich konnen sie ganz verschwinden,
doch fehlen sie vollstandig nur selten und dann auch nur an
solchen Stellen, an denen der tuberculose Process zum Stillstand
gekommen ist.
Wenn in dem tuberculosen Gewebe Riesenzellen vorkommen,
dann liegen die Bacillen vorzugsweise im Innern dieser Gebilde.
Bei sehr langsam fortschreitenden tuberculosen Processen ist
das Innere der Riesenzellen gewohnlich die einzige Statte, wo
die Bacillen zu finden sind. In diesem Falle umschliesst die
Mehrzahl der Riesenzellen einen oder wenige Bacillen und es
macht einen iiberraschenden Eindruck, in weiten Strecken des
Schnittpraparates immer neuen Gruppen von Riesenzellen zu
begegnen, von denen fast jede einzelne in dem weiten, von
braungefarbten Kernen umschlossenen Raum ein oderzwei win-
zige, fast im Centrum der Riesenzelle schwebende, blau-gefarbte
Stabchen enthalt. Oft sind die Bacillen nur in kleinen Gruppen
von Riesenzellen, selbst nur in einzelnen Exemplaren anzu-
treffen, wahrend gleichzeitig viele andere Riesenzellen frei davon
sind. Dann sind die bacillenhaltigen, wie aus ihrer Grosse und
Lage zu schliessen ist, die jungeren Riesenzellen, die bacillen-
freien dagegen die alteren und es lasst sich annehmen, dass auch
die letzteren urspriinglich Bacillen umschlossen, dass diese
aber abgestorben oder in den bald zu erwahnenden Dauerzu-
stand iibergegangen sind. Nach Analogic der von Weiss,
Friedlaender und Laulamie beobachteten Bildung von Riesen-
zellen um Fremdkorper, wie Pflanzenfasern und Strongyluseier,
826 Medical Classics
wird man sich das Verhaltniss der Riesenzellen zu den Bacillen
so vorstellen konnen, dass auch hier die Bacillen als Fremd-
korper von den Riesenzellen enigeschlossen werden und des-
wegen ist selbst dann, wenn die Riesenzelle leer gefunden wird,
alle ubrigen Verhaltnisse aber auf tuberculose Processe deuten,
die Vermuthung gerechtfertigt, dass sie friiher einen oder mehr-
ere Bacillen beherbergt hat und diese zu ihrer Eutstehung Veran-
lassung gegeben haben.
Auch ungefarbt in unpraparirtem Zustande sind die Bacillen
der Beobachtung zuganglich. Es ist dazu erforderlich, von
solchen Stellen, welche bedeutende Mengen von Bacillen en-
thalten, z. B. von einem grauen Tuberkelknotchen aus der
Lunge eines an Impftuberculose gestorbenen Meerschweinchens
ein wenig Substanz unter Zusatz von destillirtem Wasser oder
besser Blutserum zu untersuchen, was, um Stromungen in der
Fliissigkeit zu vermeiden, am zweckmassigsten im hohlen Ob-
jecttrager geschieht. Die Bacillen erscheinen dann als sehr
feine Stabchen, welche nur Molecularbewegung zeigen, aber
nicht die geringste Eigenbewegung besitzen.
Unter gewissen spater zu erwahnenden Verhaltnissen bilden
die Bacillen schon im thierischen Korper Sporen und zwar ent-
halten die einzelnen Bacillen mehrere, meistens 1 bis 6 Sporen,
von ovaler Gestalt, welche in gleichmassigen Abstanden auf
die Lange des Bacillus vertheilt sind.
In Bezug auf das Vorkommen der Bacillen bei den verschied-
enen tuberculosen Erkrankungen des Menschen und der Thiere
konnte bis jetzt folgendes Material untersucht werden:
I) Lorn Menschen: 11 Falle von Miliartuberculose. Die
Bacillen wurden in den Miliartuberkeln der Lungen niemals
vermisst; oft waren allerdings in solchen Knotchen, deren Cen-
trum keine Kernfarbung mehr annimmt, auch keine Bacillen
mehr zu finden, dann waren sie aber am Rande des Tuberkels
noch in kleinen Gruppen Vorhanden und in jiingeren, noch nicht
im Centrum verkasten Knotchen in um so grosserer Menge zu
(p. 223) finden. Sie konnten ausser in den Lungen auch in den
Miliar-tuberkeln der Milz, Leber und Niere nachgewiesen werden.
Sehr reichlich fanden sie sich in den grauen Knotchen der Pia
Die Aetiologie der Tuberculose 827
mater bei Meningitis basilaris. Auch die bei mehreren Fallen
untersuchten verkasten Bronchialdriisen enthielten zum Theil
dichte Schwarme von Bacillen und darunter viele sporenhaltige,
zum Theil in das Driisengewebe eingebettete Tuberkel mit einer
von epitheloiden Zellen umgebenen Riesenzelle im Centrum und
im Innern der Riesenzelle einige Bacillen.
12 Falle yon kasiger Bronchitis und Pneumonie (in 6 Fallen
Cavernenbildung). Das Vorkommen der Bacillen beschrankte
sich meistens auf den Rand des Kasig infiltrirten Gewebes, war
daselbst aber mehrfach ein sehr reichliches. Auch im Innern
der infiltrirten Lungenpartien trifft man bisweilen auf Bacillen-
nester. Ungemein zahlreich finden sich die Bacillen in den
meisten Cavernen. Die bekannten kleinen kasigen Brockchen
im Caverneninhalt bestehen fast ganz aus Bacillenmassen.
Unter den Bacillen, welche in den kasig erweichten Herden und
in den Cavernen sich befinden, wurden einige Male zahlreiche
mit Sporen versehene angetroflfen. In grosseren Cavernen
kommen sie mit anderen Bacterien vermischt vor, waren aber
leicht von diesen zu unterscheiden, weil bei der angegebenen
Farbungsmethode nur die Tuberkelbacillen die blaue Tinction
behalten, die anderen Bacterien, wie schon erwahnt wurde, eine
braune Farbe annehmen.
1 Fall von solitarem, mehr als haselnussgrossen Tuberkel des
Gehirns. Die kasige Masse des Tuberkels war von einem zellen-
reichen Gewebe eingeschlossen, in welches viele Riesenzellen
sich eingebettet fanden. Die meisten Riesenzellen enthielten
keine Parasiten, aber stellenweise traf man Gruppen von Riesen-
zellen, von denen jede einen oder auch zwei Bacillen enthielt.
2 Falle von Darmtuberculose. In den Tuberkelknotchen,
welche sich um die Darmgeschwiire gruppirten, konnten die
Bacillen besonders gut nachgewiesen werden und zwar fanden
sie sich auch hier wieder vorzugsweise zahlreich in den jiingsten
und kleinsten Knotchen. In den zu diesen beiden Fallen ge-
horigen Mesenterialdrusen waren die Bacillen ebenfalls in gros-
ser Menge vorhanden.
3 Falle von frisch exstirpirten scrophulosen Drizsen. Nur in
zweien derselben konnten in Riesenzellen eingeschlossene Bacil-
len nachgewiesen werden.
Medical Classics
828
4 Falle von fungoser Gelenksentziindung. In zwei Fallen
wurden ebenfalls nur in vereinzelten kleinen Gruppen von
Riesenzellen Bacillen gefunden.
II) Von Thieren: 10 Falle von Perlsucht mit verkalkten
Knoten in den Lungen, mehrfach auch im Peritoneum und ein-
mal am Pericardium. In sammtlichen Fallen fauden sich die
Bacillen und zwar vorwiegend im Innern von Riesenzellen,
welche in dem die kalkigen Massen umschliessenden Gewebe
sich befinden. Die Vertheilung der Bacillen ist meistens eine
so gleichmassige, dass unter zahlreichen Riesenzellen kaum eine
zu finden ist, welche nicht einen oder mehrere, mitunter bis zu
20 Bacillen umschliesst. In einem dieser Falle konnten die
Bacillen zugleich in den Bronchialdriisen und in einem zweiten
in den Mesenterialdriisen nachgewiesen werden.
3 Falle, in denen die Lungen von Rindern nicht die bekannten
verkalkten, mit hockriger Oberflache versehenen Knoten der
gewohnlichen Perlsucht, sondern glattwandige, mit dickbreiiger,
kaseartiger Masse gefullte, kuglige Knoten enthielten. Ge-
wohnlich wird diese Form nicht zur Tuberculose gerechnet,
sondern als eine Bronchiectasis aufgefasst. Auch in der Um-
gebung dieser Knoten fanden sich Riesenzellen und in diesen
die Tuberkelbacillen.
Eine verkaste Hals-Lymphdriise vom Schwein enthielt eben-
falls die Bacillen.
In den Organen eines an Tuberculose gestorbenen Huhnes
und zwar sowohl in den Tuberkelknoten des Knochenmarks, als
in den eigenthumlichen grossen Knoten des Darms, der Leber
und Lunge befanden sich grosse Mengen von Tuberkelbacillen.
Von 3 spontan an Tuberculose gestorbenen Aften wurden die
mit unzahligen Knotchen durchsetzten Lungen, Milz, Leber
Netz und die verkasten Lymphdrusen untersucht und uberall
in den Knotchen oder deren nachsten Umgebung die Bacillen
gefunden.
Von spontan erkrankten Thieren kamen noch 9 Meerschwein-
chen und 7 Kaninchen zur Untersuchung, welche ebenfalls
sammtlich in den Tuberkelknotchen die Bacillen aufwiesen.
Ausser diesen Fallen von spontaner Tuberculose stand mir
Die Aetiologie der Tuberculose 829
noch eine nicht unbedeutende Zahl von Thieren zur Verfugung,
welche durch Impfung mit den verschiedensten tuberculosen
Substanzen inficirt waren, namlich mit grauen und verkasten
Tuberkeln menschlicher Lungen, mit Sputum von Phthisikern,
mit Tuberkelmassen von spontan erkrankten Affen, Kaninchen
und Meerschweinchen, mit Massen aus verschiedenen sowohl
verkalk ten, als auch kasigen perisuchtigen Rinderlungen und
schliesslich auch durch Weiterimpfung der in dieser Weise er-
haltenen tuberculosen Affectionen. Die Zahl der so inficirten
Thiere belief sich auf 172 Meerschweinchen, 32 Kaninchen und
5 Katzen. Der Nachweis der Bacillen muss te sich in der Mehr-
zahl dieser Falle auf die Untersuchung der immer in grosser
Menge vorhandenen Tuberkelknotchen der Lungen beschranken.
In diesen wurden die Bacillen nicht ein einziges Mai vermisst;
oft waren sie ausserordentlich zahlreich, mitunter auch sporen-
haltig, aber nicht selten waren sie in den angefertigten Pra-
paraten auch nur in wenigen, jedoch unzweifelhaften Exem-
plaren zufzufinden.
Bei der Regelmassigkeit des Vorkommens der Tuberkelbacillen
muss es auffallend erscheinen, dass sie bisher von Niemandem
gesehen sind. Doch erklart sich dies daraus, dass die Bacillen
ausserordentlich kleine Gebilde und meistens so sparlich an Zahl
sindj namentlich wenn sich ihr Vorkommen auf das Innere der
Riesenzellen beschrankt, dass sie schon aus diesem Grunde ohne
ganz besondere Farbenreactionen dem aufmerksamsten Beo-
bachter entgehen miissen. Wenn sie sich aber auch in grosseren
Mengen beisammen finden, sind sie mit feinkornigem Detritus
in einer Weise untermengt und dadurch verdeckt, dass auch
dann ihr Erkennen im hochsten Grade erschwert ist.
Uebrigens exsistiren einige Angaben iiber Befunde von Micro-
organismen in tuberculos veranderten Geweben. So erwahnt
Schuller in seiner Schrift iiber scrophulose und tuberculose
Gelenkleiden, dass er constant Micrococcen gefunden habe.
Zweifellos muss es sich dabei, ebenso wie bei den von Klebs in
Tuberkeln gefundenen kleinsten beweglichen Kornchen um etwas
andereSj als die von mir gesehenen Tuberkelbacillen, welche
unbeweglich und stabchenformig sind, gehandelt haben. Ferner
830 Medical Classics
hat Aufrecht, wie er in dem ersten Heft seiner pathologischen
Mittheilungen berichtet, unter einer Anzahl von Kaninchen,
welche er mit perlsuchtigen oder tuberculosen Substanzen in-
ficirt hatte, bei drei von diesen Thieren im Centrum der Tuber-
kelknotchen neben zwei verschiedenen Micrococcusarten auch
kurze stabchenfdrmige Gebilde gefunden, deren Langsdurch-
messer den Querdurchmesser nur um die Halfte iibertraf. Die
Tuberkelbacillen sind aber mindestens 5 Mai so lang als dick,
oft noch viel langer im Verhaltniss zur Dicke, ausserdem kom-
men sie bei reiner Tuberculose niemals mit Micrococcen oder
anderen Bacterien vermengt im Tuberkel vor. Es ist deswegen
ausserordentlich unwahrscheinlich, dass Aufrecht die wirklichen
(p. 224) Tuberkelbacillen gesehen hat; ware es der Fall, dann
hatte er auch in menschlichen Tuberkeln und in der Perlsucht-
lunge die Bacillen nachweisen mussen und es hatte ihm das
auffallende Verhaltniss zwischen Bacillen und Riesenzellen
nicht entgehen konnen.
Auf Grund meiner zahlreichen Beobachtungen halte ich es
fur erwiesen, dass bei alien tuberculosen Affectionen des Men-
schen und der Thiere constant die von mir als Tuberkelbacillen
bezeichneten und durch characteristische Eigenschaften von
alien anderen Microorganismen sich unterscheidenden Bacterien
vorkommen. Aus diesem Zusammentreffen von tuberculoser
Affection und Bacillen folgt indessen noch nicht, dass diese
beiden Erscheinungen in einem ursachlichen Zusammenhange
stehen, obwohl ein nicht geringer Grad von Wahrscheinlichkeit
fur diese Annahme sich aus dem Umstande ergiebt, dass die
Bacillen sich vorzugsweise da finden, wo der tuberculose Process
im Entstehen oder Fortschreiten begriffen ist, und dort ver-
schwinden, wo die Krankheit zum Stillstand kommt.
Um zu beweisen, dass die Tuberculose eine durch die Ein-
wanderung der Bacillen veranlasste und in erster Linie durch
das Wachsthum und die Vermehrung derselben bedingte para-
sitische Krankheit sei, mussten die Bacillen vom Korper isolirt,
in Reinculturen so lange fortgezuchtet werden, bis sie von
jedem etwa noch anhangenden, dem thierischen Organismus
Die Aetiologie der Tuberculose 831
entstammenden Krankheitsprodukt befreit sind, und schliesslich
durch die Uebertragung der isolirten Bacillen auf Thiere das-
selbe Krankheitsbild der Tuberculose erzeugt werden, welches
erfahrungsgemass durch Impfung mit natiirlich entstandenen
Tuberkelstoffen erhalten wird.
Mit Uebergehung der vielen Vorversuche, welche zur Losung
dieser Aufgabe dienten, soli auch hier wieder die fertige Methode
geschildert werden. Das Princip derselben beruht auf der
Verwerthung eines festen durchsichtigen Nahrbodens, welcher
auch bei Bruttemperatur seine feste Consistenz behalt. Die
Vortheile dieser von mir in die Bacterienforschung eingefuhrten
Methode der Reincultur habe ich in einer fruheren Publication
ausfuhrlich auseinandergesetzt. Dass durch dieselbe die Losung
der gewiss nicht einfachen Aufgabe, die Tuberkelbacillen rein
zu cultiviren, erreicht wurde, ist mir ein neuer Beweis fur die
Leistungsfahigkeit dieser Methode.
Serum von Rinder- oder Schafblut, welches moglichst rein
gewonnen ist, wird in durch Wattepfropf verschlossene Reagens-
glaschen gefullt und sechs Tage hindurch taglich eine Stunde
lang auf 58° C. erwarmt. Durch dieses Verfahren gelingt es,
wenn auch nicht immer, so doch in den meisten Fallen, das
Serum vollkommen zu sterilisiren. Dann wird es auf 65° C.
mehrere Stunden hindurch und zwar so lange erwarmt, bis es
eben erstarrt und fest geworden ist. Das Serum erscheint nach
dieser Behandlung als eine bernsteingelbe, vollkommen durch-
scheinende oder nur schwach opalescirende, fest gallertartige
Masse und darf, wenn es sich mehrere Tage lang in Brut-tem-
peratur befindet, nicht die geringste Entwicklung von Bac-
teriencolonien zeigen. Geht die Erhitzung iiber 75 ° hinaus,
oder dauert sie zu lange, dann wird das Serum undurchsichtig.
Um eine grosse Flache zur Anlage der Culturen zu erhalten,
lasst man das Serum bei einer moglichst geneigten Lage der
Reagensglaser erstarren. Fur sole he Culturen, welche der un-
mittelbaren microscopischen Untersuchung zuganglich gemacht
werden sollen, wird das Serum in flachen Uhrglaschen oder in
hohlen Glasklatzchen zum Erstarren gebracht.
Medical Classics
832
Auf dieses erstarrte Blutserum, welches einen durchsichtigen,
bei Bruttemperatur fest bleibenden Nahrboden bildet, werden die
tuberculosen Substanzen und zwar in folgender Weise gebracht.
Der einfachste Fall, in welchem das Experiment fast ohne
Ausnahme gelingt, ist gegeben, wenn ein soeben an Tuberculose
gestorbenes, order ein zu diesem Zwecke getodtetes tuberculoses
Thier zur Verfugung steht. Zuerst wird die Haut mit kurz vor-
her ausgegluhten Instrumenten uber Brust und Bauch zur Seite
gelegt. Mit einer ebenfalls gegliihten Scheere und Pincette
werden alsdann die Rippen in der Mitte durchschnitten, die
Yordenvand des Brustkorbes, ohne dass die Bauchhohle dabei
eroftnet wird, entfernt, so dass die Lungen zu einem grossen Theil
freigelegt sind. Die Instrumente sind nun nochmals mit anderen
eben desinficirten zu vertauschen, einzelne Tuberkelknotchen
oder Partikelchen derselben von der Grosse eines Hirsekornes
mit der Scheere schnell aus dem Lungengewebe herauszupra-
pariren und sofort mit einem kurz vorher ausgegluhten, in einen
Glasstab eingeschmolzenen Platindraht in das Reagensglas auf
die Flache des erstarrten Blutserum zu iibertragen. Selbst-
verstandlich darf der Wattepfropf nur moglichst kurze Zeit
geliiftet werden. In dieser Weise werden eine Anzahl Reagens-
glaser, etwa sechs bis zehn an der Zahl mit Tuberkelsubstanz
versehen, weil selbst bei der vorsichtigsten Manipulation nicht
alle Glaser frei von zufalligen Verunreinigungen bleiben.
Lymphdrusen, die in beginnender Verkasung sich befinden,
eignen sich ebenso gut zu diesem Experiment, wie Lungen-
tuberkel; weniger gut dagegen der Eiter aus geschmolzenen
Lymphdrusen, welcher meistens nur sehr wenige oder gar kerne
Bacillen enthalt.
Schwieriger ist die Cultur der Bacillen unmittelbar aus mensch-
lichen tuberculosen Organen, oder aus perlsiichtiger Lunge.
Ich habe Objecte dieser Art, deren Entnahme aus dem Korper
ich nicht selbst mit den vorher erwahnten Vorsichtsmassregeln
besorgen konnte, sorgfaltig und wiederholt mit Sublimatlosung
abgewaschen, dann die oberflachlichen Schichten mit gegliihten
Instrumenten abgetragen und die Impfsubstanz aus einer Tiefe
Die Aetioiogie der Tuberculose 833
genommen, von der sich erwarten liess, dass Faulnissbacterien
bis dahin noch nicht gedrungen se in konnten.
Die in der geschilderten Weise mit Tuberkelsubstanz ver-
sehenen Reagensglaschen kommen in den Brutapparat und
miissen dauernd bei einer Temperatur von 37 bis 38° C. gehalten
werden. In der ersten Woche ist keine merkliche Veranderung
zu bemerken. Tritt eine solche ein und bilden sich schon in
den ersten Tagen etwa von der Impfsubstanz ausgehend oder
gar entfernt von derselben schnell um sich greifende Bacterien-
wucherungen, die sich gewohnlich als weisse, graue oder gelbliche
Tropfen, oft auch unter Yerflussigung des festen Blutserum, zu
erkennen geben, so handelt es sich um Verunreinigungen, und
das Experiment ist missgliickt.
Die aus dem Wachsthum der Tuberkelbacillen hervorgehenden
Culturen erscheinen dem unbewaffneten Auge zuerst in der
zweiten Woche nach der Aussaat, gewohnlich erst nach dem
zehnten Tage, als sehr kleine Punktchen und trocken aussehende
Schiippchen, welche, je nachdem die Tuberkelmasse bei der
Aussaat mehr oder weniger zerquetscht und durch reibende
Bewegungen mit einer grosseren Flache des Nahrbodens in Be-
riihrung gebracht wurde, das ausgelegte Tuberkelstiickchen in
geringerem oder weiterem Umkreise umlagern. Wenn sich nur
sehr wenige Bacillen in dem Aussaatmaterial befanden, dann
gelingt es kaum, die Bacillen aus dem Gewebe frei zu machen
und unmittelbar auf den Nahrbo den zu bringen, in diesem Falle
entwickeln sich inre Colonien im Innern des ausgelegten Gewebs-
stiickchens und man sieht, wenn dasselbe transparent genug (p.
225) ist, z. B. in Stiickchen, welche scrophulosen Driisen ent-
nommen sind, bei durchfallendem Licht dunklere, bei auffallen-
dem Licht dagegen weisslich erscheinende Punkte au ftreten.
Mit Hiilfe einer schwachen, ungefahr 30 bis 40 fachen \ergros-
serung sind die Bacillencolonien schon gegen Ende der ersten
Woche wahrzunehmen. Sie erscheinen als sehr zierliche, spin-
delformige und meistens S formige, aber auch in anderen ahn-
lichen Figuren gekriimmte Gebilde, welche, wenn sie am Deck-
glas ausgebreitet, gefarbt und mit starken Vergrosserungen
untersucht werden, nur aus den bekannten ausserst feinen
834 Medical Classics
Bacillen bestehen. Bis zu einem gewissen Grade schreitet im
Laufe von drei bis vier Wochen das Wachsthum dieser Colonien
fort, sie vergrossem sich zu platten, den Umfang eines Mohn-
kornes meistens nicht erreichenden, schuppenartigen Stiickchen,
welche dem Nahrboden lose aufliegen, niemals selbststandig in
denselben eindringen, oder ihn verfliissigen. Die Colonie der
Bacillen bildet ausserdem eine so compakte Masse, dass das
kleine Schiippchen von dem starren Blutserum mit einem Platin-
draht im Zusammenhang leicht abgehoben und nur unter An-
wendung eines gewissen Druckes zerbrockelt werden kann.
Das iiberaus langsame Wachsthum, welches nur bei Bruttem-
peratur zu erreichen ist, die eigenthiimliche schuppenartige
trockene und feste Beschaffenheit dieser Bacillencolonieen
findet sich bei keiner anderen bis jetzt bekannten Bacterienart
wieder, so dass eine Verwechselung der Culturen von Tuberkel-
bacillen mit denjenigen anderer Bacterien ummoglich und schon
bei nur geringer Uebung nichts leichter ist, als zufallige Verun-
reinigungen der Culturen sofort zu erkennen. Das Wachsthum
der Colonien ist, wie gesagt, nach einigen Wochen beendigt und
eine weitere Vergrosserung tritt wahrscheinlich aus dem Grunde
nicht ein, weil die Bacillen jeder Eigenbewegung entbehren und
nur durch den Wachsthumsprocess selbst auf dem Nahrboden
verschoben werden, was bei der langsamen Vermehrung der
Bacillen natiirlich nur in sehr geringen Dimensionen erfolgen
kann. Um nun eine solche Cultur im Gange zu erhalten, muss
sie einige Zeit nach der ersten Aussaat, ungefahr nach 10 bis 14
Tagen auf einen neuen Nahrboden iibertragen werden. Dies ges-
chieht so, dass einige Schiippchen mit dem gegliihten Platindraht
abgenommen und in ein frisches mit sterilisirtem, erstarrten Blut-
serum versehenes Reagensglas ubertragen, daselbst auf dem
Nahrboden zerdriickt und moglichst ausgebreitet werden. Es
entstehen dann in dem gleichen Zeitraum wieder schuppenartige,
trockene Massen, welche zusammenfliessen und je nach der
Ausdehnung der Aussaat einen mehr oder weniger grossen Theil
der Blutserumflache iiberziehen. In dieser Weise werden die
Culturen fortgesetzt.
Die Tuberkelbacillen lassen sich auch noch auf anderen
Die Aetiologie der Tuberculose 835
Nahrsubstraten kultiviren, wenn letztere ahnliche Eigenschaften
wie das erstarrte Blutserum besitzen. So wachsen sie beispiels-
weise auf einer mi t Agar-Agar bereiteten, bei Brutwarme hart
bleibenden Gallerte, welche einen Zusatz von Fleischinfus und
Pepton erhalten hat. Doch bilden sie auf diesem Nahrboden
nur unformliche kleine Brocken, niemals so characteristische
Vegetationen, wie auf dem Blutserum.
Urspriinglich habe ich die Tuberkelbacillen nur aus den
Lungentuberkeln von Meerschweinchen kultivirt, die mit tuber-
culosen Substanzen inficirt waren. Die aus verschiedenen
Quellen abstammenden Culturen hatten also eine Art Zwischen-
stufe, den Korper des Meerschweinchens, zu passiren. Hierbei
hatte es aber, ebenso wie bei der Uebertragung einer Cultur
von einem Reagensglas in ein anderes, leicht zu Irrthumern
kommen konnen, wenn zufallig andere Bacterien mit verimpft
wurden oder wenn etwa bei den Versuchsthieren, was garnicht
selten ist, spontane Tuberkulose auftritt. Um diese Fehler-
quellen zu vermeiden, bedurfte es besonderer Massregeln, welche
sich aus den Beobachtungen iiber das Verhalten der diese Ver-
suche am meisten gefahrdenden spontanen Tuberculose ergaben.
Unter hunderten von eben angekauften Meerschweinchen,
welche gelegentlich anderer Versuche zur Section kamen, habe
ich nicht ein einziges tuberculoses gefunden. Die spontane
Tuberculose kam immer nur vereinzelt und niemals vor Ablauf
von drei bis vier Monaten vor, nachdem die Thiere sich mit
tuberculos inficirten in dem namlichen Raume befunden hatten.
Bei Thieren, welche spontan tuberculos erkrankt waren, fanden
sich ausnahmslos die Bronchialdriisen ungemein vergrossert und
eitrig geschmolzen, meistens auch in der Lunge ein grosser
kasiger Heerd mit weit vorgeschrittenem Zerfall im Centrum,
so dass es einige Male ganz wie in menschlichen Lungen zu
achter Cavernenbildung gekommen war. Die Tuberkelent-
wickelung in den Unterliebsorganen war hinter derjenigen in
den Lungen weit zuriick. Die Schwellung der Bronchialdriisen
und der Beginn des Processes in den Athmungsorganen lassen
keinen Zweifel dariiber, dass die spontane Tuberculose dieser
Thiere eine Inhalationstuberculose ist, welche aus der Aufnahme
836 Medical Classics
einiger weniger oder moglicherweise nur eines einzelnen Infec-
tionskeimes entstanden ist und deswegen sehr langsam verlauft.
Ganz anders verhalt sich die Impftuberculose. Die Impfstelle
befand sich bei den Thieren am Bauch, in der Nahe der Inguin-
aldrusen. Diese schwollen auch zuerst an und gaben damit
ein friihes und untriigliches Kennzeichen fur das Gelingen der
Impfung. Die Tuberculose verlief, weil von vornherein eine
grossere Menge des Infectionsstoffes einverleibt wurde, unver-
gleichlich schneller als die spontane Tuberculose, und bei der
Section dieser Thiere wurden die Milz und Leber starker tuber-
culos verandert gefunden, als die Lunge. Es ist deswegen
durchaus nicht schwierig, die spontane Tuberculose vbn der
Impftuberculose bei den Versuchsthieren zu unterscheiden. Mit
Beriicksichtigung aller dieser Verhaltnisse liess sich wohl anneh-
men, dass, wenn mehrere eben angekaufte Meerschweinchen in
gleicher Weise und mit dem gleichen Material geimpft und von
anderen Thieren getrennt in einem besonderen Kafig gehalten
wurden, und dann sammtlich gleichzeitig und schon nach kurzer
Frist in der geschilderten, fiir Impftuberculose characteristischen
Weise erkrankten, dass dann die Entstehung der Tuberculose
nur auf die Wirkung der verimpften Substanz zuriick zu fuhren
ist.
In der angedeuteten Weise wurde denn auch verfahren und
unter alien Cautelen (vorhergehende Desinfection der Impf-
stelle, Benutzung von kurz vorher gegluhten Instrumenten)
mit der auf ihre Virulenz zu priifenden Substanz jedesmal vier
bis sechs Meerschweinchen geimpft. Der Erfolg war ein durch-
weg gleichmassiger; bei sammtlichen Thieren, welche mit frischen
tuberkelbacillenhaltigen Massen geimpft wurden, war die kleine
Impfwunde fast immer schon am folgenden Tage verklebt, sie
blieb etwa acht Tage lang unverandert, dann bildete sich ein
knotchen, welches sich entweder vergrosserte ohne aufzubrechen
oder, was meistens der Fall war, sich in ein flaches trockenes
Geschwur verwandelte. Schon nach 1 Wochen waren die auf
der Seite der Impfwunde gelegenen Leistendriisen, bisweilen
auch die Achseldrusen, bis zu Erbsengrosse geschwollen. Von
da ab magerten die Thiere schnell ab und starben nach vier bis
Die Aetiologie der Tuberculose 837
sechs Wochen oder wurden, um jede Combination mit etwa
spater eintretender spontaner Tuberculose auszuschliessen, ge-
todtet. In den Organen aller dieser Thiere, und zwar vorzugs-
weise in der Milz und Leber, fanden'sich die bei Meerschwein-
chen so sehr characteristischen, bekannten tuberculosen Ver-
anderungen. Dass in der That bei dieser Versuchsanordnung
sie Infection der Meerschweinchen nur durch die verimpften
Substanzen bewirkt vrarde, geht auch noch daraus hervor, dass
(p. 226) in mehreren Versuchsreiben mit Impfung einer scro-
phulosen Driise, fungoser Massen von einem Gelenk, in welchen
beiden Fallen keine Tuberkelbacillen aufgefunden werden konn-
ten, ferner nach Verimpfung von Lungentuberkeln eines Af fen,
welche 2 Monate lang trocken und mit eben solchen, welche
einen Monat lang in Alcohol aufbewahrt gewesen waren, auch
nicht ein einziges von den geimpften Thieren erkrankte, wahr-
end die mit bacillenhaltigen Massen geimpften ausnahmslos
vier Wochen nach der Impfung schon hochgradig tuberculos
waren.
Von solchen Meerschweinchen, welche durch Impfung mit
Tuberkeln aus der Affenlunge, mit Miliartuberkeln aus Gehirn
und Lunge vtim Menschen, mit kasigen Massen aus phthisischer
Lunge, mit Knoten aus den Lungen und vom Peritoneum perl-
siichtiger Rinder inficirt waren, wurden nun in der friiher ge-
schilderten Weise Culturen der Tuberkelbacillen ausgefiihrt.
Es stellte sich heraus, dass ebenso wie das Krankheitsbild,
welches die aufgezahlten verschiedenen Substanzen beim Meer-
schweinchen hervorrufen, immer das gleiche ist, so auch die
erhaltenen Bacillenculturen sich nicht im Geringsten von ein-
ander unterscheiden. Im Ganzen wurden 15 solcher Rein-
culturen von Tuberkelbacillen gemacht, und zwar 4 von Meer-
schweinchen, welche mit Affentuberculose inficirt waren, 4 von
mit Perlsucht, 7 von mit menschlichen tuberculosen Massen in-
ficirten Meerschweinchen.
Um aber auch jeden Einwand auszuschliessen, dass durch
die vorhergehende Verimpfung der tuberculosen Massen auf
Meerschweinchen eine Aenderung in der Natur der Bacillen,
moglicherweise ein Gleichwerden der bis dahin verschiedenen
838 Medical Classics
Organismen bewirkt sei, wurde versucht, die Tuberkel-Bacillen
unmittelbar aus den spontan tuberculos erkrankten Organen
von Menschen und Thieren zu cultiviren.
Dieser Versuch gelang mehrfach, und es wurden Reinculturen
erhalten aus zwei menschlichen Lungen mit Miliar tuberkeln,
aus einer eben solchen mit kasiger Pneumonie, zweimal aus
dem Inhalt von kleinen Cavernen phthisischer Lungen, einmal
aus verkasten Mesenterialdriisen und zweimal aus frisch exstir-
pirten scrophulosen Driisen, ferner zweimal aus perlsiichtiger
Rinderlunge und dreimal aus den Lungen vbn spontan an Tu-
berculose erkrankten Meerschweinchen. Auch diese Culturen
glichen einander vollkommen und ebenso denen, welche auf
dem Umwege der Verimpfung auf Meerschweinchen erhalten
waren, so dass an der Identitat der bei den verschiedenen tuber-
culosen Processen vorkommenden Bacillen nicht gezweifelt
werden kann.
In Bezug auf diese Reinculturen habe ich noch zu erwahnen,
dass Klebs, Schuller und Toussaint ebenfalls Microorganismen
aus tuberculosen Massen geziichtet haben. Alle drei Forscher
fanden, dass die Culturfliissigkeiten nach der Infection mit
Tuberkelstoff schon nach zwei bis drei Tagen sich trubten und
zahlreiche Bacterien enthielten. Bei den Versuchen von Klebs
traten schnell bewegliche kleine Stabchen auf, Schuller und
Toussaint erhielten Micrococcen. Ich habe mich wiederholt
davon uberzeugt, dass die Tuberkelbacillen in Fliissigkeiten
nur sehr kiimmerlich wachsen, dieselben auch niemals triibe
machen, weil sie ganz unbeweglich sind, und wenn ein Wachsthum
stattfindet, dies sich erst im Verlauf von drei bis vier Wochen
zu erkennen giebt. Die genannten Forscher mussen es daher
mit anderen Organismen als mit den Tuberkelbacillen zu thun
gehabt haben.
Bis dahin war durch meine Untersuchungen also festgestellt,
dass das Vorkommen von characteristischen Bacillen regel-
massig mit Tuberculose verkniipft ist, und dass diese Bacillen
sich aus tuberculosen Organen gewinnen und in Reinculturen
isoliren lassen. Es blieb nunmehr noch die wichtige Frage zu
beantworten, ob die isolirten Bacillen, wenn sie dem Thier-
Die Aetiologie der Tuberculose 839
korper wieder einverleibt- werden, den Krankheitsprocess der
Tuberculose auch wieder zu erzeugen vermogen.
Um be] der Losung dieser Frage, in welcher der Schwerpunkt
der ganzen Untersuchung iiber das Tuberkelvirus liegt, jeden
Irrthum auszuschliessen, wurden moglichst verschiedene Reihen
von Experimenten angestellt, welche wegen der Bedeutung der
Sache einzeln aufgezahlt werden sollen.
Zunachst wurden Versuche mit einfacher Verimpfung der
Bacillen in der friiher geschilderten Weise angestellt.
1. Versuch. Von sechs eben angekauften und in einem und
demselben Kafig gehaltenen Meerschweinchen wurden vier am
Bauch mit Bacillen Cultur geimpft, welche aus menschlichen
Lungen mit Miliartuberkeln gewonnen und 54 Tage lang in
funf Umziichtungen cultivirt waren. Zwei Thiere blieben un-
geimpft. Bei den geimpften Thieren schwollen nach 14 Tagen
die Inguinaldriisen, die Impfstellen verwandelten sich in ein
Geschwiir und die Thiere magerten ab. Nach 32 Tagen starb
eines der geimpften Thiere. Nach 35 Tagen wurden die ubrigen
getodtet. Die geimpften Meerschweinchen, sowohl das spontan
gestorbene, als die drei getodteten, wiesen hochgradige Tuber-
culose der Milz, Leber und Lungen auf; die Inguinaldriisen
waren stark geschwollen und verkast, die Bronchialdriisen wenig
geschwollen. Die beiden nicht geimpften Thiere zeigten keine
Spur von Tuberculose in den Lungen, der Leber oder Milz.
2. Versuch. Von acht Meerschweinchen wurden 6 mit Ba-
cillen-Cultur geimpft, welche aus der tuberculosen Lunge eines
Affen abstammend 95 Tage lang in acht Umziichtungen cultivirt
war. Zwei Thiere blieben zur Controle ungeimpft. Der Ver-
lauf war genau derselbe, wie im ersten Versuch. Die 6 geimpften
Thiere wurden bei der Section hochgradig tuberculos, die beiden
ungeimpften gesund gefunden, als sie nach 32 Tagen getodtet
"wurden.
3 - Versuch. Von 5 Meerschweinchen wurden 5 Cultur
geimpft, die von perlsiichtiger Lunge herriihrte, 72 Tage alt und
6 mal umgeziichtet war. Die 5 geimpften Thiere zeigten sich,
als nach 34 Tagen sammtlich Thiere getodtet wurden, tuber-
culos, das ungeimpfte gesund.
Medical Classics
840
4. Versuch. Eine Anzahl Thiere (Mause, Ratten, Igel, ein
Hamster, Tauben, Frosche), iiber deren Empfanglichkeit fur
Tuberculose noch nichts bekannt ist, wurden mit Cultur geimpft,
welche von tuberculoser Lunge eines Affen gewonnen und 113
Tage lang ausserhalb des Thierkorpers fortgeziichtet war. 4
Feldmause, welche 53 Tage nach der Impfung getodtet wurden,
hatten zahlreiche Tuberkelknotchen in der Milz, Leber und
Lunge, ebenso verhielt sich ein gleichfalls 53 Tage nach der
Impfung getodteter Hamster.
In diesen 4 ersten Versuchsreihen hatte die Verimpfung von
Bacillen-CuJturen am Bauch der Versuchsthiere also eine ganz
genau ebenso verlaufende Impftuberculose hervorgebracht, wie
wenn frische tuberculose Substanzen verimpft gewesen waren.
In den nachstfolgenden Versuchen wurde die Impfsubstanz
in die vordere Augenkammer von Kaninchen gebracht, um zu
erfahren, ob auch bei dem so modificirten Impfverfahren das
kunstlich cultivirte Tuberkelvirus denselben Effect haben wurde,
wie das natiirliche.
5. Versuch. Drei Kaninchen erhielten ein kleines Brock-
chen einer Cultur (von kasiger Pneumonie menschlicher Lunge
abstammend und 89 Tage lang fortgeziichtet) in die vordere
Augenkammer. Es entwickelte sich schon nach wenigen Tagen
eine intensive Iritis, die Hornhaut wurde bald triibe und gelb-
grau gefarbt. Die Thiere magerten sehr schnell ab, wurden
nach 25 Tagen getodtet und ihre Lungen von zahllosen Tuber-
kelknotchen durchsetzt gefunden.
(p. 227) 6. Versuch. Von 3 Kaninchen erhalt eines eine In-
jection von reinem Blutserum in die vordere Augenkammer, die
beiden anderen eine Injection mit dem namlichen Blutserum, mit
welchem aber einige Brockchen von einer Cultur (aus Perlsucht-
lungen abstammend und 91 Tage lang fortgeziichtet) verrieben
sind. Bei den beiden letzten Kaninchen traten dieselben Er-
scheinungen wie im vorigen Versuch ein. Schnell verlaufende
Iritis und Triibung der Cornea. Nach 28 Tagen werden die
Thiere getodtet. Das erste mit reinem Blutserum injicirte
Kaninchen ist vollkommen gesund, die Lungen der beiden
Die Aetiologie der Tuberculose 841
andern Thiere sind mit unzahligen Tuberkelknotchen gleichsam
uberschiittet.
7. Yersuch. Von 4 Kaninchen erhalt das erste reines Blut-
serum in die vordere Augenkammer, dem zweiten wird die
Kaniile der Spritze, welche Blutserum mit Zusatz von BaciUen-
Cultur (von Affentuberculose abstammend, 132 Tage lang fort-
geziichtet) enthalt, in die vordere Augenkammer gefuhrt, der
Stempel aber nicht bewegt, so dass nur eine minimale Menge
der Fliissigkeit in den Humor aq. gelangen kann. Dem 3. und
4. Kaninchen werden von dem mit der Bacillen Cult ur versetzten
Blutserum mehrere Tropfen in die vordere Augenkammer in-
jicirt. Bei den beiden letzten Thieren entwickelt sich wieder
Iritis, Panophthalmitis und es folgt sehr schnelle Abmagerung.
Bei dem zweiten Kaninchen dagegen bleibt das Auge an-
fangs unverandert, aber im Verlauf der a. Woche en,tstehen
einzelne weissgelbliche Knotchen auf der Iris in der Nahe der
Einstichstelle und es entwickelt sich von da ausgehend eine
regelrechte Iristuberculose. Auf der Iris entstehen immer neue
Knotchen, sie faltet sich, alimalig triibt sich dann die Cornea
und die weiteren Veranderungen entziehen sich der Beobachtung.
Nach 30 Tagen werden diese vier Thiere getodtet. Das erste
ist vollkommen gesund, beim zweiten linden sich ausser den
erwahnten Veranderungen am Auge, die Lymphdriisen am Kiefer
und neben der Ohrwurzel geschwollen und von gelbweissen
Herden durchsetzt, die Lungen und iibrigen Organe sind noch
frei von Tuberculose. Die beiden letzten Kaninchen haben
wieder unzahlige Tuberkeln in der Lungen.
8. Versuch. 6 Kaninchen werden mit Cultur, welche von
menschlicher Lunge mit Miliartuberkeln abstammt und 105 Tage
lang fortgeziichtet ist, in derselben Weise wie im vorhergehenden
Versuch, das zweite Thier nur durch Einstich in die vordere
Augenkammer ohne Injection, inficirt. Es entwickelt sich bei
alien 6 Thieren Iristuberculose, bei einigen auch eine uber die
Nachbarschaft der Impfstelle sich langsam ausbreitende In-
filtration der Conjunctiva mit Tuberkelknotchen.
Das Resultat dieser Versuche mit Impfung in die vordere
Augenkammer war, wenn moglichst geringe Mengen von Tuber-
842 Medical Classics
kelbacillen eingefuhrt wurden, ein ganz dem von Cohnheim,
Salomonsen und Baumgarten erhaltenen entsprechendes.
Ich begnugte mich damit aber noch nicht, sondern stellte
noch fernere Versuche an mit Injection der Bacillen-Culturen
in die Bauchhohle oder direct in den Blutstrom und suchte
schliesslich auch noch solche Thiere, deren Infection mit Tuber-
culose nicht leicht gelingt, durch den kiinstlich geziichteten
Infectionsstoff tuberculos zu machen.
9. Versuch. Von zwolf Meerschweinchen erhielten zehn Blut-
serum, welches mit Bacillen Cultur (von Affentuberculose ab-
stammend und 142 Tage geziichtet) versetzt war, in die Bauch-
hohle injicirt. Dem elften wurde reines Blutserum in die
Bauchhohle injicirt und das zwolfte, welches eine ganz frische,
bedeutende Bisswunde am Bauche hatte, blieb ohne Einspritzung.
Von den Thieren, welche die Injection erhalten hatten, starben
je eins nach 10, 13, 16, 17, 18 Tagen. Die ubrigen wurden am
2.5. Tage nebst den Controlthieren getodtet. Bei den zuerst
gestorbenen war das grosse Netz stark verdickt, zusammenge-
ballt und mit einer derben gelblichweissen Masse infiltrirt.
Unter dem Microscop stellte sich diese Masse als auszahllosen
Tuberkelbacillen bestehend heraus, welche fast sammtlich mit
sehr deutlichen Sporen versehen waren. Die spater gestorbenen
resp. getodteten Thiere dieser Reihe hatten, ausser der Infiltra-
tion des Netzes, bereits Tuberkeleruptionen in Milz und Leber.
Die Controlthiere wurden vollkommen gesund befunden.
10. Versuch. Eine Anzahl weisser Ratten war zwei Monate
lang fast ausschliesslich mit den Leichen tuberculoser Thiere
gefuttert. Von Zeit zu Zeit wurde eine Ratte getodtet und
untersucht. Einige Male wurden vereinzelte kleine graue
Knotchen in den Lungen dieser Thiere gefunden, die meisten
waren ganz gesund geblieben. Auch einfache Impfungen mit
tuberculosen Substanzen und mit Culturen aus denselben hatten
keinen Effect bei diesen Thieren gehabt, obwohl sie wiederholt
versucht wurden. Nachdem die Fiitterung mit tuberculosen
Massen mehrere Wochen aufgehort hatte, erhielten 5 von diesen
Ratten eine Injection mit Bacillen-Cultur (von Affentuberculose
und 142 Tage geziichtet) in die Bauchhohle. Fiinf Wochen
Die Aetiologie der Tuberculose 843
spater wurden dieselben getodtet und in den Lungen, sowie in
der stark vergrosserten Milz dieser Thiere, zahllose Tuberkel-
knotchen gefunden. Dieser Versuch ist nicht rein, weil die
Fiitterung mit tuberculosen Massen vorhergegangen war, aber
ich erwahne ihn deshalb, weil es gelungen war, bei Ratten,
welche alien Infectionsstoffen gegeniiber sich mindestens ebenso
resistent verhalten wie Hunde, durch die Injection der Bacillen-
Culturen eine regelrechte Tuberculose zu erzeugen.
11. Versuch. Von 12 Kaninchen erhielten 2 einen halben
Ccm. reinen Blutserums in die Ohrvene injicirt. 4 Kaninchen
erhielten in derselben Weise Blutserum mit Cultur (von Affen-
tuberculose abstammend und 178 Tage fortgeziichtet), 3 Kanin-
chen Blutserum mit Cultur (aus menschlicher phthisischer Lunge
abstammend und 103 Tage fortgeziichtet) und die 3 letzten
Blutserum mit Cultur (von Perlsuchtlungen abstammend und
121 Tage lang geziichtet). Fur jede dieser Gruppen wurde
eine besondere Spritze benutzt. Die beiden ersten Kaninchen
blieben munter und kraftig, alle iibrigen magerten rapide ab
und fingen schon in der zweiten Woche an schwer zu athmen.
Nach 18 Tagen stirbt das erste Thier (Einspritzung mit Cultur
phthisischer Lunge), nach 19 Tagen das zweite und dritte (beide
hatten Einspritzungen mit Cultur von Affen tuberculose erhalten),
nach 21 Tagen das vierte (Einspritzung mit Cultur von Perl-
sucht), nach 25 Tagen das funfte (mit Cultur von Phthisis in-
ficirt), nach 26 und 27 Tagen das sechste und siebente (mit
Cultur von Affen tuberculose inficirt), am 30 und 31. Tage zwei
weitere Thiere. Das letzte und die beiden Controlthiere wurden
am 38. Tage nach der Injection getodtet.
In dem Verhalten der Lunge und der iibrigen Organe der
mit verschiedenen Culturen inficirten Thiere konnte kein Unter-
schied wahrgenommen werden. Bei sammtlichen Thieren fanden
sich zahllose Miliartuberkel in den Lungen. Auch die Leber
und die Milz von alien diesen Thieren enthielten ausserordent-
lich viele Tuberkel, doch waren dieselben bei den zuerst ge-
storbenen nur mikroskopisch klein; bei den spater gestorbenen
hatten sie sich schon so weit entwickelt, dass sie macroscopisch
sichtbar wurden und bei einem Kaninchen zeigten sich auch im
Medical Classics
844.
Netz, im Zwerchfell und im Mesenterium viele mit blossem Auge
erkennbare Miliartuberkel. Die beiden Controlthiere wurden
bei der Section ohne jede Tuberkelablagerung in irgend einem
Organ gefunden.
12. Versuch. Zwei ausgewachsene kraftige Katzen erhielten
(p. 228) eine Injection in die Bauchhohle mit Blutserum, welches
mit Cultur (von Affentuberkulose erhalten und 162 Tage lang
fortgeziichtet) verrieben war. Die eine starb nach 19 Tagen.
Das Netz war mit einer derben weisslichen Masse infiltrirt und
stellen-weise liber einen Centimeter dick. Der serose Ueber-
zug der Darme und das Peritoneum hatten ihren Glanz verloren,
die Milz war stark vergrossert. Die Infiltration des Netzes
bestand ebenso wie bei den Meerschweinchen, welche eine In-
jection mit Bacillenkultur in die Bauchhohle erhalten hatten,
aus dichten, grosstentheils in Zellen eingebetteten Massen yon
Tuberkelbacillen. Zu einer makroskopisch erkennbaren Tuber-
keleruption war es noch nicht gekommen; aber microscopisch
liessen sich zahllose Tuberkel in Lunge, Leber und Milz nach-
weisen. Die zweite Katze wurde nach 43 Tagen getodtet und
es fanden sich bei derselben sehr zahlreiche hirsekorngrosse
Tuberkelknotchen in den Lungen, Milz und Netz, verhaltniss-
massig wenige in der Leber.
13. Versuch. Einer mehrere Jahre alten Hiindin wurden
zwei Cubikcentimeter Blutserum, welchem Cultur (von mensch-
licher Miliartuberkulose abstammend und 94 Tage fortgeziichtet)
beigemengt war, in die Bauchhohle injicirt. In den ersten
beiden Wochen nach der Injection war an dem Thiere keine
Veranderung zu bemerken, dann verlor es an Munterkeit, frass
weniger und vom Ende der dritten Woche an zeigte sich eine
deutliche Auftreibung des Leibes. Zu Anfang der funften Woche
wurde es getodtet. In der Bauchhohle befand sich ein ziemlich
reichlicher Erguss einer klaren, schwachgelblichen Flussigkeit.
Das Netz, Mesenterium und Mutterbander waren mit sehr vielen
Tuberkelknotchen besetzt, ebenso die Oberflache des Darms und
der Blase. Die vergrosserte Milz, die Leber und Lungen ent-
hielten Zahllose Miliartuberkel. Von den Injectionsstellen war
Die Aetiologie der Tuberculose 845
nichts mehr zu erkennen und nirgends eine Spur von kasigem
Eiter.
Es bedarf wohl kaum der Erwahnung, dass die zu alien diesen
Versuchen benutzten Spritzen vor jedem Gebrauch durch ein-
stiindiges Erhitzen auf 160 bis 170° C. sicher desinficirt waren.
Vielfach wurden die Tuberkelknotchen, welche sowohl durch
Impfung als durch Injection mit den Bacillenkulturen erhalten
waren mikroskopisch untersucht und vollkommen identisch
gefunden mit den gewohnlichen spontan oder nach Impfung
mit tuberkulosen Massen bei diesen Thieren entstandenen
Tuberkeln. Sie hatten ganz dieselbe Anordnung der zelligen
Elemente und waren auch vielfach mit Riesenzellen versehen,
welche ebenso wie diejenigen der spontanen Tuberkel Bacillen
einschlossen. Ferner wurden aus den Tuberkeln, welche ver-
mittelst der Bacillenculturen erhalten waren, von neuem die
Bacillen in Reinculturen isolirt und mit diesen sowohl als mit
den Tuberkeln Impfversuche angestellt, welche ganz dasselbe
Resultat wie Impfungen mit menschlichen Tuberkeln oder
Perlsuchtlunge ergaben. Also auch in dieser Beziehung ver-
hielten sich die durch Infection mit Culturen erhaltenen Tuberkel
wie die natiirlich vorkommenden.
Blickt man auf diese Versuche zuruck, so ergiebt sich, dass
eine nicht geringe Zahl von Versuchsthieren, denen die Bacillen-
culturen in sehr verschiedener Weise, namlich durch einfache
Impfung in das subcutane Zellgewebe, durch Injection in die
Bauchhohle oder in die vordere Augenkammer, oder direct in
den Blutstrom beigebracht waren, ohne nur eine Ausnahme
tuberculos geworden waren und zwar hatten sich bei ihnen
nicht etwa einzelne Knotchen gebildet, sondern es entsprach die
ausserordentliche Menge der Tuberkel der grossen Zahl der
eingefuhrten Infectionskeime. An anderen Thieren war es
gelungen durch Impfung moglichst geringer Mengen von Bacillen
in die vordere Augenkammer ganz dieselbe tuberkulose Iritis zu
erzeugen, wie sie in den bekannten fur die Frage der Impftuber-
kulose ausschlaggebenden Versuchen von Cohnheim, Salomonsen
und Baumgarten nur durch achte tuberkulose Substanz erhalten
war.
Medical Classics
846
Eine Verwechselung mit spontaner Tuberkulose oder eine
zufallige unbeabsichtigte Infection der Versuchsthiere mit Tu-
berkel-Virus ist in diesen Experimenten aus folgenden Griinden
ausgeschlossen. Erstens kann weder die spontane Tuberkulose
noch eine zufallige Infection in einem so kurzen Zeitraum diese
massenhafte Eruption von Tuberkeln veranlassen. Zweitens
blieben die Controlthiere, welche genau in derselben Weise wie
die inficirten Thiere behandelt wurden, nur mit dem einzigen
Untershied, dass sie keine Bacillencultur erhielten, gesund.
Drittens kam bei zahlreichen zu andern Versuchszwecken in
derselben Weise mit anderen Substanzen geimpften und inji-
cirten Meerschweinchen und Kaninchen niemals dieses typische
Bild von Miliartuberkulose vor, welches nur dann entstehen
kann, wenn der Korper auf einmal mit einer grossen Menge von
Infectionskeimen gewissermassen uberschiittet wird.
Alle diese Thatsachen zusammengenommen berechtigen zu
dem Ausspruch, dass die in den tuberkulosen Substanzen vor-
kommenden Bacillen nicht nur Begleiter des tuberculosen Pro-
cesses, sondern die Ursache desselben sind, und dass wir in den
Bacillen das eigentliche Tuberkelvirus vor uns haben.
Damit ist auch die Moglichkeit gegeben, die Grenzen der
unter Tuberculose zu verstehenden Krankheit zu ziehen, was
bisher nicht mit Sicherheit geschehen konnte. Es fehlte an
einem bestimmten Kriterium fur die Tuberculose, und der Eine
rechnete dazu Miliartuberculose, Phthisis, Scrophulose,Perlsucht
u. s. w., ein Anderer hielt vielleicht mit ebenso viel Recht alle
diese Krankheitsprocesse fur different. In Zukunft wird es
nicht schwierig sein zu entscheiden, was tuberculos und was
nicht tuberculos ist. Nicht der eigenthiimliche Bau des Tu-
berkels, nicht seine Gefasslosigkeit, nicht das Vorhandensein
von Riesenzellen wird den Ausschlag geben, sondern der Nach-
weis der Tuberkelbacillen, sei es im Gewebe durch Farben-
reaction, sei es durch Cultur auf erstarrtem Blutserum. Dies
Kriterium als das massgebende angenommen, mvissen nach
meinen Untersuchungen Miliartuberculose, kasige Pneumonie,
kasige Bronchitis, Darm- und Driisentuberculose, Perlsucht des
Rindes, spontane und Impftuberculose bei Thieren fiir identisch
Die Aetiologie der Tuberculose 847
erkiart werden. Ueber Scrophulose und fungose Gelenkaffec-
tionen sind meine Untersuchungen zu wenig zahlreich, um ein
Urtheil zu ermoglichen. Jeden falls gehort ein grosser Theil
der scrophulosen Driisen- und Gelenkleiden zur achten Tuber-
culose. Vielleicht sind sie ganz mit der Tuberculose zu ver-
einigen. Der Nachweis von Tuberkelbacillen in den verkasten
Driisen eines Schweines, in den Tuberkelknotchen eines Huhnes
lasst vermuthen, dass die Tuberculose auch unter den Haus-
thieren eine grossere Verbreitung hat, als gemeinhin angenommen
wird und es ist sehr wiinschenswerth auch nach dieser Richtung
hin das Verbreitungsgebiet der Tuberculose genau kennen zu
lernen.
Nachdem die parasitische Natur der Tuberculose somit
festgestellt ist, miissen zur Vervollstandigung der Aetiologie
noch die Fragen beantwortet werden, woher die Parasiten
stammen und wie sie in den Korper gelangen.
In Bezug auf die erste Frage ist es nothwendig zu entscheiden,
ob der I'nfectionsstoff nur unter Verhaltnissen, wie sie im thieris-
chen Korper gegeben sind, sich entwickeln, oder ob er, wie z. B.
die Milzbrandbacillen auch unabhangig vom thierischen Or-
ganismus an irgend welchen Stellen in der frieien Natur seinen
Entwickelungsgang durchmachen kann.
(p. 229) Es ergab sich nun in mehreren Versuchen, dass die
Tuberkelbacillen nur bei Temperaturen zwischen 30 und 41 0 C.
wachsen. Unter 30° fand ebenso wie bei 42° innerhalb drei
Wochen nicht das geringste Wachsthum statt, wahrend bei-
spielsweise Milzbrandbacillen noch bei 20° und zwischen 42°
und 43° C. kraftig wachsen. Schon auf Grund dieser einen
Thatsache kann die aufgestellte Frage ehtschieden werden. Im
gemassigten Klima ist ausserhalb des Thierkorpers keine Ge-
Iegenheit fur eine mindestens 2 Wochen anhaltende gleich-
massige Temperatur von liber 30*° C. geboten. Es folgt daraus,
dass die Tuberkelbacillen in ihrem Entwickelungsgang lediglich
auf den thierischen Organismus angewiesen, also nicht gelegent-
liche, sondern achte Parasiten sind, und nur aus dem thierischen
Organismus stammen konnen.
Auch die zweite Frage, wie die Parasiten in den Korper ge-
848 Medical Classics
laneen, ist zu beantworten. Die weit iiberwiegende Mehrzahl
aller Falle von Tuberculose nimmt ihren Anfang in den Respi-
rationsvregen und der Infectionsstoff macht sich zuerst in den
Lungen oder in den Bronchialdriisen bemerklich. Es ist also
hiernach sehr wahrscheinlich, dass die Tuberkelbacillen ge-
wohnlich mit der Athemluft, an Staubpartikelchen haftend, ein-
geathmet werden. Ueber die Art und Weise, wie dieselben in
die Luft kommen, kann man wohl nicht in Zweifel sein, wenn
man erwagt, in welchen Unmassen die im Caverneninhalt vor-
handenen Tuberkelbacillen von Phthisikern mit dem Sputum
ausgeworfen und iiberall hin verscbleppt werden.
Um uber das Vorkommen der Tuberkelbacillen im phthisi-
schen Sputum eine Anschauung zu gewinne, habe ich wiederholt
die Sputa von einer grossen Reihe von Phthisikern untersucht
und gefunden, dass in manchen derselben keine, aber ungefahr
in der Halfte der Falle ganz ausserordentlich zahlreiche Bacillen,
darunter auch sporenhaltige, vorhanden waren. Nur beilaufig
sei bemerkt, dass in einer Anzahl Proben von Sputum nicht
phthisisch Kxanker die Tuberkelbacillen niemals gefunden
wurden. Mit solchem frischen bacillenhaltigen Sputum ge-
impfte Thiere wurden ebenso sicher tuberculos, als wie nach
Impfung mit Miliartuberkeln.
Aber auch nach dem Eintrocknen verloren derartige infec-
tiose Sputa ihre Yirulenz nicht. So wurden vier Meerschwein-
chen durch Impfung mit zwei Wochen altem, trockenen Sputum,
femer vier Meerschweinchen durch Impfung mit vier Wochen
lang trocken aufbewahrtem Sputum und weitere vier Meer-
schweinchen durch acht Wochen hindurch trocken gehaltenes
Sputum ganz in derselben Weise tuberculos, wie nach Infection
mit frischem Material. Demnach lasst sich wohl annehmen,
dass das am Boden, Kleidern u. s. w. eingetrocknete phthisische
Sputum langere Zeit seine Virulenz bewahrt und, wenn es ver-
staubt in die Lungen gelangt, daselbst Tuberculose erzeugen
kann. Fermuthlich wird die Haltbarkeit der Virulenz von der
Sporenbildung der Tuberkelbacillen abhangen und es ist in
dieser Beziehung wohl zu berucksichtigen, dass die Sporen-
Die Aetiologie der Tuberculose 849
bildung, wie wir an einigen Beispielen gesehen haben, bereits
im thierischen Organismus selbst und nicht wie bei den Milz-
brandbacillen ausserhalb desselben vor sich gebt.
Auf die Verhaltnisse der erworbenen oder ererbten Disposi-
tion, welche in der Aetiologie der Tuberculose unzweifelhaft
eine bedeutende Rolle spielen, jetzt schon eingehen zu wollen,
wiirde zu sehr in das Gebiet der Hypothese fuhren. Nach dieser
Richtung hin bedarf es noch eingehender Untersuchungen, ehe
ein Urtheil gestattet ist. Nur auf einen Punkt, welcher zur
Erldarung mancher rathselhaften Erscheinungen dienen kann,
mochte ich aufmerksam machen; das ist das uberaus langsame
Wachsthum der Tuberkelbacillen. Dasselbe bewirkt hochst
wahrscheinlich, dass die Bacillen nicht, wie beispielsweise die
ungemein schnell wachsenden Milzbrandbacillen, von jeder be-
liebigen kleinen Verletzung des Korpers aus zu inficiren \er-
mogen. Wenn man ein Thier mit Sicherheit tuberculos machen
will, dann muss der Infectionsstoff in das subcutane Gewebe,
in die Bauchhohle, in die vordere Augenkammer, kurz an einen
Ort gebracht werden, wo die Bacillen Gelegenheit haben, sic
in geschiitzter Lage vermehren und Fuss fassen zu konnen.
Infectionen von flachen Hautwunden aus, welche nicht in das
subcutane Gewebe dringen, oder von der Cornea gelingen nur
ausnahmsweise. Die Bacillen werden wieder elimimrt, ehe sie
sich einnisten konnen. _
Hieraus erklart sich, weshalb die Sectionen von tu v.rcu osen
Leichen nicht zur Infection fuhren, auch v/enn kleine c mtt-
wunden an den Handen mit tuberculosen Massen m Beruhrung
kommen. Kleine schwache Hautschnitte smd eben kerne tur
das Eindringen der Bacillen geeigneten Impfwunden. e n ic e
Bedingxingen werden sich auch fur das Haften der in Ie ^ ,
gerathenen Bacillen gel tend machen. Es werden wa rsc ein
besondere, das Einnisten der Bacillen begungstigen e i om >
v?ie stagnirendes Secret, Entblossung der c eim^au
schutzenden Epithel u. s. w., zu Hulfe kommen muss< " \
die Infection zu ermoglichen. Es ware sonst 'aum zu 'v /
dass die Tuberculose, mit der wohl jeder Mensch, na
850 Medical Classics
an dicht bevolkerten Orten, mehr oder weniger in Beriihrung
kommt, nicht noch haufiger inficirt, als es in Wirklichkeit ge-
schieht.
Fragen wir nun danach, welche weitere Bedeutung den bei der
Untersuchung der Tuberculose erhaltenen Resultaten zukommtj
so ist es zunachst als ein Gewinn fur die Wissenschaft anzusehen,
dass es zum ersten Male gelungen ist, den vollen Beweis fur
die parasitische Natur einer menschlichen Infectionskrankheit,
und zwar der wichtigsten von alien vollstandig zu liefern. Bisher
war dieser Beweis nur fur Milzbrand erbracht, wahrend von
einer Anzahl den Menschen betreffenden Infectionskrankheiten
z. B. von Recurrens, von den Wundinfectionskrankheiten,
Lepra, Gonorrhoe nur das gleichzeitige Vorkommen der Para-
siten mit dem pathologischen Process bekannt war, ohne dass
das ursachliche Verhaltniss zwischen diesen beiden erwiesen
werden konnte. Es lasst sich erwarten, dass die Aufklarungen,
welche uber die Aetiologie der Tuberculose gewonnen sind, auch
fur die Beurtheilung der ubrigen Infectionskrankheiten neue
Gesichtspunkte ergeben, und dass die Untersuchungsmethoden,
welche sich bei der Erforschung der Tuberculose-Aetiologie
bewahrt haben, auch bei der Bearbeitung anderer Infections-
krankheiten von Nutzen sein werden. Ganz besonders mochte
dies letztere fur Untersuchungen uber diejenigen Krankheiten
gelten, welche wie Syphilis und Rotz mit der Tuberculose am
nachsten verwandt sind und mit ihr zusammen die Gruppe der
Infections-Geschwulstkrankheiten bilden.
In wie weit die Pathologie und Chirurgie die Kenntnisse uber
die Eigenschaften der Tuberculose-Parasiten verwerthen konnen,
ob beispielsweise der Nachweis der Tuberkelbacillen im Sputum
zu diagnostischen Zwecken benutzt werden kann, ob die sichere
Bestimmung mancher local-tuberculoser Affectionen auf die
chirurgische Behandlung derselben von Einfluss sein wird, und
ob nicht moglicher Weise auch die Therapie aus weiteren Er-
fahrungen iiber die Lebensbedingungen der Tuberkelbacillen
Nutzen ziehen kann, das alles zu beurtheilen, ist nicht meine
Aufgabe.
Meine Untersuchungen habe ich im Interesse der Gesund-
Die Aetiologie der Tuberculose 851
heitspflege vorgenommen, und dieser wird auch, wie ich hoffe,
der grosste Nutzen daraus erwachsen.
(p. 230) Bisher war man gewohnt, die Tuberculose als den
Ausdruck des socialen Elends anzusehen und hoffte von dessen
Besserung auch eine Abnahme dieser Krankheit. Eigentliche
gegen die Tuberculose selbst gerichtete Massnahmen kennt des-
wegen die Gesundheitspflege noch nicht. Aber in Zukunft wird
man es im Kampf gegen diese schreckliche Plage des Men-
schengeschlechtes nicht mehr mit einem unbestimmten Etwas,
sondern mit einem fassbaren Parasiten zu thun haben, dessen
Lebensbedingungen zum grossten Theil bekannt sind und noch
weiter erforscht werden konnen. Der Umstand, dass dieser
Parasit nur im thierischen Korper seine Existenzbedingungen
findet und nicht, wie die Milzbrandbacillen, auch ausserhalb
desselben unter den gewohnlichen natiirlichen Verhaltnissen ge-
deihen kann, gewahrt besonders giinstige Aussichten auf Erfolg
in der Bekampfung der Tuberculose. Es miissen vor alien
Dingen die Quellen, aus denen der InfectionsstofF fliesst, so
weit es in menschlicher Macht liegt, verschlossen werden. Eine
dieser Quellen und gewiss die hauptsachlichste ist das Sputum
der Phthisiker, um dessen Verbleib und Ueberfuhrung in einen
unschadlichen Zustand bis jetzt nicht geniigend Sorge getragen
ist. Es kann nicht mit grossen Schwierigkeiten verkmipft sein,
durch passende Desinfectionsverfahren das phthisische Sputum
unschadlich zu machen und damit den grossten Theil des tuber-
culosen Infectionsstoffes zu beseitigen. Gewiss verdient daneben
auch die Desinfection der Kleider, Betten u. s. w., welche von
Tuberculosen benutzt wurden, Beachtung.
Eine andere Quelle der Infection mit Tuberculose bildet
unzweifelhaft die Tuberculose der Hausthiere, in erster Linie
die Perlsucht. Damit ist auch die Stellung gekennzeichnet,
welche die Gesundheitspflege in Zukunft der Frage nach der
Schadlichkeit des Fleisches und der Milch von perlsiichtigen
Thieren einzunehmen hat. Die Perlsucht ist identisch mit der
Tuberculose des Menschen und also eine auf diesen iibertrag-
bare Krankheit. Sie ist deswegen ebenso wie andere vom Thier
auf den Menschen iibertragbare Infectionskrankheiten zu be-
852 Medical Classics
handeln. Mag nun die Gefahr, welche aus dem Genuss von
perlsiichtigem Fleisch oder Milch resultirt, noch so gross oder
noch so Idein sein, vorhanden ist sie und muss deswegen ver-
mieden werden. Es ist hinlanglich bekannt, dass milzbrandi-
ges Fleisch von vielen Personen und oft lange Zeit hindurch,
ohne jeden Nachtheil genossen ist, und doch wird Niemand
daraus den Schluss ziehen, dass der Verkehr mit solchem Fleisch
zu gestatten sei.
In Bezug auf die Milch perlsfichtiger Kfihe ist es bemerkens-
werth, dass das Uebergreifen des tuberculosen Processes auf
die Milchdrfise von Thierarzten nicht selten beobachtet ist,
und es ist deswegen wohl moglich, dass sich in solchen Fallen
das Tuberkelvirus der Milch unmittelbar beimischen kann.
Es liessen sich noch eine Anzahl weiterer Gesichtspunkte
fiber Massregeln aufstellen, welche auf Grund unserer jetzigen
Kenntnisse fiber die Aetiologie der Tuberculose zur Einschran-
kung dieser Krankheit dienen konnten, doch wfirde eine Be-
sprechung derselben hier zu weit ffihren. Wenn sich die Ueber-
zeugung, dass die Tuberculose eine exquisite Infectionskrank-
heit ist, unter den Aerzten Bahn gebrochen haben wird, dann
werden die Fragen nach der zweckmassigsten Bekampfung der
Tuberculose gewiss einer Discussion unterzogen werden und sich
von selbst entwickeln.
The Etiology of Tuberculosis
BY
DR. ROBERT KOCH
Member of the Imperial Board of Health Administration
(From a lecture given at the Physiological Society of Berlin on March 24)
Published in Berliner klinische Wochenschrift, 19: 221-230, 1882
Translated by Dr. William deRouville
^ILLEMIN’s discovery that tuberculosis is trans-
missible to animals has found varied confirma-
tion, as is well known, but also apparently well
founded opposition, so that, up to a few years
ago, it remained undecided as to whether or
not tuberculosis is an infectious disease. Since
then, however, the inoculations into the anterior chamber of the
eye, carried out first by Cohnheim and Salomonsen and later by
Baumgarten, and, in addition, the inhalation experiments of
Tappeiner and others have proven the transmissibility of tuber-
culosis beyond a doubt, and, in the future, it must be awarded a
place among the infectious diseases.
If the number of victims which a disease claims is taken as a
measure of its importance, then all diseases, especially the most
feared contagious diseases, plague, cholera, etc., must take a
place far behind that of tuberculosis. Statistics show that 1/7
of all people die of tuberculosis, and if only the productive middle
aged class is considered, tuberculosis carries away a third and
often more of these. Thus the public health has cause enough
for devoting its attention to such a fatal disease, wholly aside
from the fact that still other conditions, of which only the re-
853
854 Medical Classics
lationship between human and bovine tuberculosis need be men-
tioned, lay a claim to the interest of hygiene.
Since it now becomes the task of the health officials to make the
infectious diseases the object of investigation from the stand-
point of public health, and thus primarily of etiology, it now ap-
pears as a pressing duty to conduct penetrating investigations
particularly of tuberculosis.
Attempts have been made repeatedly to investigate the nature
of tuberculosis thoroughly, but up to now they have been fruit-
less. The so frequently successful staining methods used for the
demonstration of pathogenic microorganisms have left this
disease in the lurch, and the attempts made to isolate and culti-
vate the virus of tuberculosis up to the present can not be re-
garded as successful; so that Cohnheim in the recently published
latest edition of his lectures in general pathology had to speak of
“the direct demonstration of the virus of tuberculosis as a yet
unsolved problem”.
In my investigations of tuberculosis, I at first followed the
known methods without obtaining any explanation as to the true
nature of the disease. However, several opportune observations
caused me to abandon these methods and to adopt others which
finally led me to positive results.
The aim of the investigations had to be directed first toward
the demonstration of some sort of parasitic organism foreign to
the body, which possibly could be explained as the cause of the
disease. This demonstration was indeed carried out successfully
by means of a certain staining method, with the aid of which char-
acteristic bacteria, previously unknown, were found in all organs
affected by tuberculosis. It would take too long to describe the
manner in which I arrived at this new procedure and therefore I
shall pass at once to its description.
The material to be examined is prepared in the usual manner
for examining for pathogenic bacteria, and either spread on the
cover slip, dned and heated or cut into sections after fixation in
alcohol. The cover slips or sections are placed in a staining solu-
tion of the following constitution: 200 c.c. of distilled water are
mixed with 1 c.c. of a concentrated alcoholic solution of methyl-
Etiology of Tuberculosis 855
ene blue, shaken up, and then 0.2 c.c. of a 10% solution of potas-
sium hydroxide is added with repeated shaking. This mixture
must show no precipitate after standing for several days. The
materials to be stained remain in this solution for 20 to 24 hours.
By heating the solution to 40°C. in a water bath this time can be
shortened to § to I hour. Following this the cover slips are cov-
ered with a concentrated aqueous solution of vesuvin which is
filtered each time before using, and after I to 2 minutes rinsed
with distilled water. When the cover slips come from the methyl-
ene blue, the attached layer appears dark blue and is markedly
(p. 222) overstained. During the treatment with vesuvin this
blue color is lost and it appears stained a faint brown. Under
the microscope all the constituents of animal tissue, that is, the
cell nuclei and their products of disintegration appear brown,
while the tubercle bacilli, on the other hand, stain a beautiful
blue. Moreover, all other bacteria which I have investigated to
date, with the exception of the lepra bacilli, take on a brown color
with this staining method. The color contrast between the
brown stained tissue and the blue tubercle bacilli is so striking
that the latter/which are present often only in very small number,
nevertheless, are to be found and identified with the greatest
certainty.
Sections are treated in an entirely similar manner. They are
transferred from the methylene blue to the filtered vesuvin solu-
tion, remain there from 15 to 20 minutes and are then rinsed in
distilled water until the blue color has disappeared and a more or
less intense brown tint is left. Following this they are dehy-
drated with alcohol, cleared in oil-of-cloves and can be examined
microscopically at once in this fluid or else finally embedded in
Canada balsam. In these preparations also the tissue constit-
uents are stained brown and the tubercle bacilli a vivid blue.
Moreover, the bacteria are not stained only by methylene
blue, but with the simultaneous operation of alkalies, take up
other anilin dyes with the exception of the brown dyes; the stain-
ing, however, is not nearly as beautiful as that with methylene
blue. Furthermore, in the staining process described, the potas-
sium solution can be replaced by sodium or ammonia, from which
856 Medical Classics
it can be concluded that the potassium itself does not play an
essential role, but it is only the strong alkalinity of the solution
that matters. The fact that the bacteria can be stained by a
stronger addition of the potassium in places where they no longer
come to view with a solution containing less potassium is further
confirmation of this. However, the tissues of the cut sections
shrink and change so much under the influence of stronger potas-
sium solutions that the latter are only exceptionally of value.
The bacteria made visible by this method show a behavior
which,, in many respects, is characteristic. They have a rod
shaped form and thus belong to the group of bacilli. They are
very thin and are from a quarter to one-half of the diameter of a
red blood corpuscle in length; however, at times they attain
greater length, up to the full diameter of a red blood cell. In
shape and size they bear a striking similarity to the lepra bacilli;-
yet they differ from the latter in that they appear a little slimmer
and pointed at the ends. Also with Weigert’s nuclear staining
method, the lepra bacilli take up the stain, which the tubercle
bacilli do not do. The bacilli are present in large numbers in all
situations where the tuberculous process is early in origin and
making rapid progress; they then usually form little groups which
are pressed closely together and at times are arranged in bundles.
Many times these lie within cells and present a picture like that
of lepra bacilli heaped within the cells. On the other hand, many
free bacilli are found. Particularly on the borders of large case-
ous foci, crowds of bacilli which are not inclosed in cells are found.
As> soon as the height of the tuberculous process is passed the
bacilli become more rare, are found only in small groups or en-
tirely alone on the edges of tuberculous foci, along with weakly
stained and at times scarcely recognizable bacilli, which are dying
or already dead. Finally, they may disappear completely, yet
they are rarely entirely absent and then only in those cases in
which the tuberculous process is arrested.
If giant cells are present in the tuberculous tissue, then the
bacilli lie chiefly within these structures. In very slowly pro-
gressing tuberculous processes the interior of the giant cells is
usually the only place in which the bacilli are to be found. In
Etiology of Tuberculosis 857
this case the majority of giant cells contain only one or a few
bacilli; and it makes a surprising impression to continually meet
new groups of giant cells in wide stretches of the cut section, which
contain one or two tiny blue rods suspended almost in the center
in the wide space surrounded by the brown stained nuclei. Often
the bacilli are seen in only small numbers of giant cells, at times
only solitary specimens are met, while at the same time many
other giant cells are free of them. In this case those containing
the bacilli are the younger ones as judged from their size and
position, the bacilli free, on the other hand, are the older ones;
and from this it can be assumed that the latter originally con-
tained bacilli, that these have died or passed over into the resting
state, which is soon to be mentioned. According to analogy with
the formation of giant cells about foreign bodies, such as vegetable
fibers and Strongylus eggs, as observed by Weiss, Friedlander and
Laulamie, one can conceive of the relationship between the giant
cells and bacilli as follows; that the bacilli, as foreign bodies,
have been engulfed by the giant cells and thus if the giant cell
is empty and all other signs indicate a tuberculous process, the
probability is that it previously harbored one or more bacilli
and that these have given cause to its origin.
In addition, the bacilli may be observed unstained in the un-
prepared condition. For this it is necessary to examine carefully
and in a hanging drop, in order to avoid streaming of the fluid,
a little material taken from locations which contain a significant
number of bacilli, for. example from a gray tubercle of a lung of a
guinea pig dead of inoculation tuberculosis. Then the bacilli
appear as very fine rods, which show only molecular movements
but have not the slightest motility of their own.
Under certain conditions, to be mentioned later, the bacilli
form spores, even in the animal body; and indeed, the single
bacillus contains several, usually 2 to 4, spores of oval form which
are distributed throughout its length.
In regard to the presence of the bacilli in the various tubercu-
lous processes in man and animals the following material has been
observed.
I) Human. 1 1 cases of miliary tuberculosis. The bacilli were
858 Medical Classics
never lacking in the miliary tubercles in the lungs; often, however,
in nodules the centers of which no longer took up the nuclear
stain, bacilli were not to be found; but here they were present,
even in greater numbers, at the edge of the tubercle and in
younger tubercles not yet caseous at the center, (p. 223) Beside
the lungs they could be demonstrated in miliary tubercles of the
spleen, liver and kidneys. They were present in abundance in
the gray nodules of the pia mater in basilar meningitis. Also,
in several cases examined, the caseous bronchial glands contained,
in part, dense swarms of bacilli many of which bore spores, and
in part, a few bacilli in the interior of giant cells and in the center
of tubercles embedded in the lymphoid tissue and composed of
epithelioid cells surrounded by giant cells.
12 cases of caseous bronchitis and pneumonia (cavity formation
in six cases). The presence of the bacilli was limited chiefly to
the edges of the caseous, infiltrated tissues, but they were fre-
quently very abundant. Occasionally nests of bacilli are en-
countered in the infiltrated portions of the lungs. In most cavi-
ties the bacilli are uncommonly numerous. The well known tiny
caseous particles in the contents of the cavities consist almost
entirely of masses of bacilli. Among the bacilli present in the
soft caseous foci and in the cavities, numbers bearing spores were
encountered at times. In large cavities they are present mixed
with other bacteria, but easily differentiated from them because,
as described in the method of staining, only the tubercle bacilli
take the blue tint, while the other bacteria, as already men-
tioned, stain brown.
1 case of solitary tubercle of the brain, larger than a hazel nut.
The caseous mass of the tubercle was surrounded by cellular tissue
in which many giant cells were embedded. The majority of
giant cells contained no parasites, but occasionally groups of
giant cell each containing one or two bacilli were met.
2 cases of intestinal tuberculosis. In the tubercles grouped
about the intestinal ulcers, the bacilli could be demonstrated es-
pecially well, and indeed, here again they were found particularly
numerous in the most recent and smallest nodules. In addition,
Etiology of Tuberculosis 8 59
the bacilli were present in large numbers in the mesenteric lymph
nodes of both these cases.
3 cases of recently excised scrofulous lymph nodes. In only
two of these could bacilli inclosed in giant cells be demonstrated.
4 cases of proliferative arthritis. In two cases bacilli were
found but only in small isolated groups of giant cells.
II) In animals. 10 cases of bovine tuberculosis with calcified
nodules in the lungs, several also in the peritoneum, and, in one
case, on the pericardium. In all cases the bacilli were present,
principally within the giant cells which were in the tissue sur-
rounding the calcified masses. The distribution of the bacilli
is so uniform that among numerous giant cells, scarcely one is to
be found that does not contain one or more bacilli, sometimes as
many as twenty. In one of these cases, the bacilli also could be
demonstrated in the bronchial lymph nodes, and in a second, in
the mesenteric nodes.
3 cases in which the lungs of cattle did not contain the usual
calcified nodules with uneven surfaces of the usual tuberculosis,
but on the contrary, smooth walled, round nodules filled with
thick, soupy, cheesy material. Usually this form is not regarded
as tuberculosis, but as bronchiectasis. However, in the vicinity
of these nodules, giant cells were found and in them the tubercle
bacilli.
One caseous cervical lymph node of a pig contained the bacilli.
In the organs of a fowl dead of tuberculosis, and, indeed, in
tubercles of the bone marrow, as well as in the peculiar nodules of
the intestines, liver and lungs, large numbers of bacilli were found.
In three monkeys, spontaneously dead of tuberculosis, the
lungs, spleen, liver, omentum, which were riddled with countless
nodules, and the caseous lymph nodes, were examined and tuber-
cle bacilli found in all the nodules or in their immediate vicinity.
Of spontaneously ill animals, nine guinea pigs and seven rabbits
came to examination, which disclosed the bacilli everywhere in
the tubercles.
•Beside these cases of spontaneous tuberculosis, there was pro-
vided for me a not inconsiderable number of animals which were
860 Medical Classics
infected by means of inoculation with various tuberculous sub-
stances; that is, Avith gray and caseous tubercles from human
beings, with sputum from consumptives, with tuberculous mate-
rial from spontaneously afflicted monkeys, rabbits and guinea
pigs, with material from various lungs of cattle with bovine tuber-
culosis, calcified as well as caseous, and finally from tuberculous
affections obtained by sub-inoculations. The number of animals
infected in this way amounts to 172 guinea pigs, 32 rabbits and
5 cats. The demonstration of the bacilli in the majority of
these cases had to be limited to examination of the tubercles of the
lungs which were always present in large numbers. In these
the bacilli were not absent a single time; often they were extra-
ordinarily numerous, at times spore bearing, only a few definitely
recognizable specimens occasionally being found in the prepara-
tions.
It is striking that in spite of the regularity of the occurrence of
the tubercle bacilli, no one up to the present has seen them. Yet
this can be explained by the act that the bacilli are extraordi-
narily tiny structures and for the most part are so scant in number,
especially when their presence is limited to the interior of the
giant cells, that without special staining methods they must es-
cape the most careful observer. Even though they are present
in large numbers, they are mixed with finely granular detritis and
obscured by it in such a way that their recognition is extremely
difficult.
Moreover, there are several accounts of micro-organisms hav-
ing been found in tissues showing the changes of tuberculosis.
Thus Schuller mentions in his paper on scrofulous and tuberculous
joint diseases that he has found micrococci constantly. Doubt-
less we are concerned here, just as in the case of Klebs, who found
extremely tiny motile granules in tubercles, with something
other than the tubercle bacilli which I observed, and which are
non-motile and rod shaped. Also Aufrecht, as he states in the
first volume of his pathological reports, has found, in the center
of tubercles of three rabbits out of a number which he infected
with tuberculous and bovine tuberculous material, short rod-
like structures along with two different types of micrococci.
Etiology of Tuberculosis 86 1
The long axes of the former measured about half the length of
the transverse diameter. The tubercle bacilli, however, are at
least five times as long as they are thick, often much longer in
comparison to their thickness; furthermore, in uncomplicated
tuberculosis, they never occur mixed with micrococci or other
bacteria in the tubercle. It is therefore most unlikely that Au-
frecht has seen the true (p. 224) tubercle bacillus. If this were
the case, then he should have been able to demonstrate it in hu-
man and bovine tuberculous lungs and the striking relationship
between the tubercle bacilli and the giant cells could not have
escaped him.
On the basis of my numerous observations I state it to be
proved that the bacteria designated by me as the tubercle bacilli
are present in all cases of tuberculous disease of man and animals,
and that they may be differentiated from all other microorgan-
isms by their characteristic properties. It does not necessarily
follow from this coincidence of the tuberculous disease and the
bacilli that the two phenomena have an original association, al-
though no small amount of probability is given to this theory by
the fact the bacilli are found chiefly where the process is beginning
Qr progressing, and that they disappear in those places where the
disease comes to a standstill.
In order to prove that tuberculosis is a parasitic disease caused
by the invasion of the bacilli and primarily influenced by the
growth and proliferation of the latter, the bacilli had to be iso-
lated from the body and cultivated in pure culture until devoid
of all adherent products of disease originating from the animal or-
ganism; and, finally, through transfer of the isolated bacilli to
animals, the same clinical picture of tuberculosis as is obtained
empirically by the injection of naturally developed tuberculous
material had to be produced.
Omitting the many preliminary investigations which led to the
solution of this problem, here again only the finished method v. ill
be described. Its principle depends on the use of a solid, trans-
parent culture medium which retains its firm consistency at in-
cubator temperature. I have described at length the ad\ amage
of this method of obtaining pure cultures, which I have ini.ro-
862 Medical Classics
duced into the study of bacteria, in an earlier publication. That
the solution of the complicated problem of cultivating the tu-
bercle bacilli in pure culture has been reached by means of the
same method, is to me an additional proof of the efficiency of
this method.
Serum of cattle or sheep blood, which is obtained as purely as
possible, is poured into cotton stoppered test tubes and daily,
for six consecutive days, is heated to a temperature of 58 °C. for
an hour at a time. By this means it is possible to sterilize the
serum completely in most instances, although not always, when
everything else may fail. Then it is heated to 6$°C. for several
hours, indeed, until it has become coagulated and firm. After
this treatment, the serum appears as amber yellow, completely
transparent or at least only slightly opalescent, firm, gelatinous
material; and does not show the slightest development of bacterial
colonies if it is left for many days at incubator temperature. In
order to obtain a large surface for the laying out of cultures the
serum is allowed to become fixed with the test tubes slanted as
much as possible. For such cultures as are to be made directly
accessible to microscopic investigation the serum is placed in flat
watch glasses or hollow glass blocks for hardening.
On this solidified blood serum, which forms a firm transparent
culture medium at incubator temperature, the tuberculous mate-
rial is placed in the following manner: —
The simplest way, in which the experiment almost without
exception succeeds, presents when an animal just dead of tuber-
culosis or one killed for this purpose is used. First the skin is
deflected over the breast and thorax with instruments just pre-
viously flamed. With a flamed pincers and clippers the ribs are
then cut in the middle and the anterior wall of the chest is re-
moved without entering the abdominal cavity, so that the lungs
lie free throughout a large extent. The instruments are now re-
placed by other freshly disinfected ones, single tubercles or par-
ticles of one of the size of a millet seed are excised from the lung
tissue quickly with the scissors and at once transferred to the
surface of the solidified blood serum in the test tube, by means of a
just previously flamed platinum wire fused into a glass rod. Nat-
Etiology of Tuberculosis 863
urally the cotton plug is removed for only the shortest possible
time. In this manner a number of test tubes, about six or ten,
are treated with tuberculous material, because, in spite of the
most cautious manipulation, not all of the tubes remain free of
accidental contamination.
Lymph glands, in which there is beginning caseation, lend
themselves to this experiment just as well as the pulmonary tu-
bercles; less well, on the other hand, the pus from broken down
glands, which usually contains very few or almost no bacilli.
The direct culture of bacilli from tuberculous human organs or
from the lungs of bovine tuberculosis is more difficult. I have
washed objects of this sort, the removal of which from the body I
was not able to care for with the previously mentioned precau-
tions, carefully and repeatedly with bichloride of mercury, then
removed the surface layers with flamed instruments and taken
the material for inoculation from the deep portions where it is to
be expected that contaminating bacteria were not yet able to
penetrate.
The test tubes, treated in the described manner with tuber-
culous material, are placed in the incubator and must remain
there constantly at a temperature from j/° to j8 °C. In the first
week no noteworthy changes are observed. If one should occur
and if rapidly growing bacterial proliferation takes place in the
first few days, spreading out from the material inoculated or
indeed at a distance from it, which usually is recognized by white,
gray or yellow drops, often with liquefaction of the blood serum,
then we are dealing with a contaminant and the experiment has
miscarried.
The cultures resulting from the growth of tubercle bacilli
first appear to the naked eye in the second week after inoculation,
usually not until after the tenth day, as very tiny points and dry
scales, which, according to whether the tuberculous material is
more or less broken up during inoculation and brought into con-
tact with a larger surface of the culture medium by means of
nibbing motions, lie about the fragments of the tubercles in tin)
or wide areas. If only a very few bacilli were present in the ma-
terial inoculated, then it is hardly ever possible to free the baci i
864 Medical Classics
from the tissue and bring them into direct contact with the cul-
ture medium. In this case they develop their colonies within
the bits of tissue and if this is transparent enough, (p. 225) if,
for example, it is in small pieces which have been taken from
scrofulous glands, whitish, shining points may be seen within it
when the light strikes it. By the aid of low magnification, ap-
proximately 30 to 40 times, the colonies may be perceived by the
end of the first week. They appear as very fine, spindle shaped,
usually S shaped or similarly bent structures, which, when spread
out on a cover glass, stained and examined under high magnifica-
tion, consist only of the exceedingly fine bacilli described. The
growth of the colonies progresses up to a certain extent during the
course of three to four weeks, as they enlarge to flat scale like
bits, which usually do not reach the size of a poppy seed in cir-
cumference, and which lie loosely on the surface of the culture
medium and never penetrate it spontaneously or liquefy it.
The colony of bacilli, furthermore, forms such a compact mass
that the little scale can be raised easily from the solidified blood
serum with a platinum wire and can be broken up only by the
exertion of a certain amount of pressure. The markedly slow
growth which is attained only at incubator temperature, the
peculiarly dry and scale like condition of these bacillary colonies
occur in no other known type of bacteria, so that confusion of the
cultures of tubercle bacilli with those of other bacteria is im-
possible; and after only a small amount of practice nothing is
easier to detect at once than accidental contamination of the
cultures. The growth of the colonies ceases after several weeks,
as has been said already, and further enlargement probably does
not occur because the bacilli are lacking in motility and are
forced out on the culture medium only through the growth proc-
ess itself, which, because of the slow proliferation of the bacilli,
naturally can proceed only in very short dimensions. In order
to keep such a culture going, it must be transplanted to new cul-
ture material at some time after the first inoculation, approxi-
mately after 10 to 14 days. This is done by taking several scales
on a flamed platinum wire and placing them in a fresh test tube
containing sterilized, solidified blood serum, crushing them on
Etiology of Tuberculosis 865
the culture medium and spreading them out as far as possible.
Then, after the same time interval, scale-like, dry masses spring
up, which coalesce and cover more or less of the surface of the
blood serum, according to the extent of their inoculation. In
this manner the culture is carried on.
The tubercle bacilli also can be cultivated on other culture
media which have properties similar to that of the blood serum.
Thus, for example, they will grow on a jelly which remains firm
at incubator temperature, and is prepared from agar-agar con-
taining an infusion of meat and peptone. However, on this
medium, they form only shapeless small flecks and never the
characteristic vegetations as on the blood serum.
Originally I cultivated tubercle bacilli only from the pulmonary
tubercles of guinea pigs which had been infected with tuberculous
material. Thus the cultures originating from various sources
had to pass through a sort of intermediary state, that is, in the
body of the guinea pig. But in this also, as in the transfer of a
culture from one test tube to another, mistakes could occur easily,
if, by chance, other bacteria were also injected or if spontaneous
tuberculosis were present in the laboratory animals, as is not
seldom the case. To avoid these sources of error, special pre-
cautions were necessary; these being obtained by observations of
spontaneous tuberculosis, which is most dangerous to this experi-
ment. Among hundreds of recently bought guinea pigs, which
opportunely came to autopsy in the course of other experiments,
I have never found a single tuberculous one. Spontaneous tuber-
culosis always occurred in isolated instances and never before the
course of 3 to 4 months during which time the animals had been
in the same room with those infected with tuberculosis. In
animals spontaneously ill of tuberculosis, I found the bronchial
lymph nodes, without exception, to be uncommonly large and
broken down into pus and usually in the lungs also a large caseous
focus with far advanced necrosis in the center, so that several
times true cavity formation had taken place exactly as in human
lungs. The development of tubercles in the abdominal viscera
lagged far behind that in the lungs. The swelling of the bron-
chial lymph nodes and the beginning of the process in the respira-
866 Medical Classics
tory apparatus leaves no doubt that the spontaneous tuberculosis
of these animals is an inhalation tuberculosis, which arises from
the taking up of only a few or possibly only a single germ and
which then progresses very slowly. Inoculation tuberculosis
acts in an entirely different manner. The site of inoculation in
these animals was in the belly in the vicinity of the inguinal
lymph nodes. These swelled first of all and thereby gave an
early and infallible sign as to the success of the inoculation. The
tuberculosis ran a much more rapid course than the spontaneous
tuberculosis, because to begin with, a larger amount of infectious
material was taken into the body; and on section of these animals,
the spleen and liver showed far more changes of tuberculosis
than did the lungs. Thus it is not at all difficult to differentiate
spontaneous tuberculosis from inoculation tuberculosis in labora-
tory animals. Bearing these considerations in mind, if a number
of newly bought guinea pigs were inoculated at the same time and
with the same material and kept segregated from other animals
in a special cage, and then, simultaneously, after a short space of
time, all became ill in the characteristic manner described for
inoculation tuberculosis, it can be assumed that the origin of the
tuberculosis was to be attributed only to the effects of the mate-
rial injected.
In the manner described and taking all precautions (previous
disinfection of the site of inoculation, use of previously flamed in-
struments), four to six guinea pigs were inoculated each time with
the material to be tested for virulence. The results were uniform
throughout. In all animals which were inoculated with fresh
material containing tubercle bacilli the tiny injection wound was
almost always crusted over on the following day. It remained
unchanged for about 8 days, then a nodule formed which either
enlarged without breaking down or, as was the usual case,
developed into a flat dry ulcer. Within two weeks the inguinal
nodes on the side of the inoculation wound, at times also the
axillary nodes, were enlarged to pea size. From then on the
animals quickly became emaciated, and died after 4 to 6 weeks,
or were killed in order to avoid any combination with a later
developing spontaneous tuberculosis. In the organs of all these
Etiology of Tuberculosis 867
animals, and chiefly in the spleen and liver, the characteristic,
well known tuberculous changes of guinea pigs were found.
That, indeed, the infection of the guinea pigs in this series of
experiments resulted only from the injected material is demon-
strated by the fact that, (p. 226) in other series of experiments
with inoculation of a scrofulous gland, and fungous material
from a joint in which no tubercle bacilli could be found, and after
injections of pulmonary tubercles (monkey), which had been
dried for two months and with some which had been kept in al-
cohol for a month, not a single one of the animals inoculated be-
came ill, while those injected with material containing bacilli
showed marked tuberculosis in four weeks without exception.
From such guinea pigs as had been infected by inoculation with
tubercles from the lungs of monkeys, with miliary tubercles from
the brain and lungs of humans, with caseous material from
phthisical lungs and with nodes from the lungs and peritoneum
of tuberculous cattle, cultures of tubercle bacilli were obtained in
the manner previously described. As a result, it was found that,
just as the clinical picture which the various substances enumer-
ated produced in the guinea pigs never varied, so the cultures of
bacilli obtained did not differ from one another in the slightest
degree. In all, fifteen such pure cultures of tubercle bacilli were
obtained and of these four were from guinea pigs which were
infected with tuberculosis from monkeys, four with bovine tuber-
culosis and seven with tuberculous material from humans.
However, in order to exclude any possible objection that a
change in the nature of the bacilli, possibly a bringing about of
similarity between previously dissimilar organisms, was caused
by the inoculation of the tuberculous material into the guinea
pigs, an attempt was made to cultivate the tubercle bacilli
directly from the spontaneously diseased organs of humans
and animals.
This experiment succeeded many times and pure cultures
were obtained from two human lungs with miliary tuberculosis,
from another with caseous pneumonia, twice from the contents
of small cavities of phthisical lungs, once from caseous mesenteric
nodes and twice from freshly extirpated scrofulous nodes, in
868 Medical Classics
addition, twice from the lungs of cattle with bovine tuberculosis
and three times from the lungs of guinea pigs spontaneously ill
of tuberculosis. Moreover, these cultures were entirely similar
to one another, just as were those obtained by the round-about
method of inoculating guinea pigs, so that the unity of identity
of the bacilli present in the various tuberculous processes can
not be doubted.
In regard to these pure cultures, I must mention that Klebs,
Schuller and Toussaint have also cultured microorganisms from
tuberculous material. All three investigators found that the
culture fluids became cloudy and contained numerous bacteria
two or three days after inoculation with tuberculous material.
In Klebs’ experiments little motile rods were soon present,
Schuller and Toussaint obtained micrococci. I have convinced
myself repeatedly that tubercle bacilli grow only sparsely in
liquids and never render it turbid, because they are entirely
non-motile and, if growth occurs, it takes three to four weeks to
become recognizable. The investigators mentioned, therefore,
must have been working with organisms other than the tubercle
bacilli.
Thus, up to this point, my investigations have established
that the presence of characteristic bacilli is regularly bound up
with tuberculosis and that these bacilli can be obtained from
tuberculous organs and isolated in pure culture. It now re-
mained to answer the weighty question as to whether the isolated
bacilli if again introduced into the body, are able to produce
the pathological processes of tuberculosis.
In order to exclude any error from the solution of this question,
wherein lies the crux of the whole investigation of the tubercle
virus, series of experiments, as varied as possible, were set up
and shall be enumerated in detail because of the significance of
the point in question.
First, experiments with simple inoculation of the bacilli in
the manner previously described were set up.
Experiment i. Of six newly bought guinea pigs which were
kept in the same cage, four were inoculated on the abdomen with
cultures of bacilli obtained from human lungs with miliary
Etiology of Tuberculosis 869
tuberculosis and cultivated for 54 days through five changes
of culture material. Two animals remained uninjected. After
14 days the inguinal nodes of the inoculated animals swelled,
the sites of injection ulcerated and the animals became emaciated.
After 32 days one of the animals inoculated died. After 35
days the remainder of the animals were killed. The injected
animals, the one which had died as well as the three which were
killed, showed advanced tuberculosis of the spleen, liver and
lungs; the inguinal nodes were greatly swollen and caseous, the
bronchial nodes but slightly swollen. Neither of the animals
which were not injected showed the slightest trace of tuberculosis
in the lungs, the liver or the spleen.
Experiment 2. Of 8 guinea pigs, 6 were inoculated with
cultures of bacilli which originated from the tuberculous lungs
of monkeys and were cultivated for 95 days with eight transfers.
Two animals remained uninjected for controls. The course was
exactly the same as in the first experiment. The six injected
animals showed advanced tuberculosis at autopsy; the two
uninjected ones were found healthy when they were killed
after 32 days.
Experiment 3. Of 6 guinea pigs, 5 were inoculated with
cultures arising from a lung of bovine tuberculosis, 72 days old,
transferred six times. The 5 injected animals were found tuber-
culous, the uninjected ones healthy, after 34 days when all the
animals were killed.
Experiment 4. A number of animals (mice, rats, hedge-hogs,
a hamster, pigeons, frogs) whose susceptibility to tuberculosis
is not known, were inoculated with cultures obtained from the
tuberculous lung of a monkey and cultivated for 1 13 days outside
of the animal body. Four field mice, killed 53 days after injec-
tion, had numerous tubercles in the spleen, liver and lungs, as
did the hamster, killed 53 days after inoculation.
In these first four experiments the inoculation of cultures
of bacilli on the abdomen of the experimental animals has thus
produced the same clinical picture of tuberculosis as when fresh
tuberculous material had been injected.
In the following experiments the material inoculated was
870 Medical Classics
placed in the anterior chamber of the eye of rabbits in order
to learn, by this means of inoculation also, whether the artificially
cultivated tubercle virus had the same effect as the natural one.
Experiment 5. Three rabbits received a tiny fragment of
a culture (obtained from caseous pneumonia of a human lung and
grown for 89 days) in the anterior chamber of the eye. After
a few days an intensive iritis developed, the cornea soon became
cloudy and yellowish gray in color. The animals quickly became
emaciated, were killed after 25 days and their lungs found riddled
with countless tubercles.
(p. 227) Experiment 6. Of 3 rabbits, one received an injection
of pure blood serum in the anterior chamber of the eye, the
other two an injection with the same blood serum with which
a bit of a culture (from a lung of bovine tuberculosis carried for
91 days) had been mixed. In the latter two rabbits the same
phenomena occurred as in the previous experiment. Iritis run-
ning a rapid course and haziness of the cornea. After 28 days
the animals were killed. The first rabbit, injected with pure
blood serum, was completely well, the lungs of both other animals
were riddled with countless tubercles.
Experiment 7. Of 4 rabbits, the first received pure blood
serum in the anterior chamber. The cannula of the syringe
which contained serum, to which a culture of bacilli (from an
ape with tuberculosis, cultivated for 132 days) was added, was
introduced into the anterior chamber of the second, but the
plunger was not moved, so that only a minimal amount of the
fluid could reach the aqueous humor. In the 3rd and 4th rabbits
several drops of serum with the culture of bacilli were injected
into the anterior chamber. In both the last two rabbits, iritis
and panophthalmitis again developed and emaciation quickly
followed.
On the other hand, in the second rabbit, the eye at first re-
mained unchanged, but in the course of the second week a few
yellowish white nodules developed on the iris in the vicinity
of the point of injection and from these a typical tuberculous
iritis developed. New nodules continually developed on the
iris, it became wrinkled, the cornea then gradually became hazy
Etiology of Tuberculosis 871
and obscured the further changes from observation. After
30 days these four animals were killed. The first was com-
pletely well, in the second, beside the changes mentioned in
the eye, the lymph glands along the jaw and next to the root
of the ear were found to be swollen and studded with yellowish
white foci; the lungs and remaining organs were, as yet, free
from tuberculosis. The last two rabbits as usual had numerous
tubercles in the lungs.
Experiment 8. Six rabbits were infected in the same manner
as the second animal in the preceding experiment with a culture
which originated from a human lung with miliar}' tuberculosis
and which was cultivated for 105 days, receiving only a needle
prick in the anterior chamber without injection. Tuberculosis
of the iris developed in all 6 animals; in some also a slowly de-
veloping infiltration of the conjunctiva with tubercles in the
region of the site of injection.
The result of these experiments of inoculation into the anterior
chamber of the eye, when only the smallest possible amount of
tubercle bacilli are introduced, was wholly in accord with those
of Cohnheim, Salmonscn, and Baumgarten.
I did not content myself with this alone, but set up still further
experiments with injections of cultures of bacilli into the ab-
dominal cavity or directly into the blood stream, and finally
sought to render such animals tuberculous with artificially
cultivated virus as are not easily infected.
Experiment 9. Of twelve guinea pigs, ten received blood
serum, to which was added a culture of bacilli (originating from
monkey tuberculosis and cultivated for 141 days) injected into
the peritoneal cavity. Pure blood serum was injected into the
peritoneal cavity of the eleventh, while the twelfth, which had
a fresh bite on the abdomen of some significance, remained
uninjected.
Of the animals injected, one died after 10, 13, 16, 17 and 18
days. The remainder were killed on the 25th day along with
the control animals. In the first to die the great omentum was
markedly thickened, matted together and infiltrated with thick
yellowish white masses. Under the microscope, these masses
Sy 2 Medical Classics
were seen to consist of countless tubercle bacilli, almost all of
which contained very definite spores. The animals which died
later, as well as those which were killed, had tuberculous eruptions
in the spleen and liver, in addition to the infiltration of the
omentum. The control animals were found to be completely
healthy.
Experiment io, A number of white rats were fed for two
months almost exclusively on the bodies of tuberculous animals.
From time to time a rat was killed and examined. Several
times small, solitary, gray nodules were found in the lungs of
these animals which, for the most part, remained healthy. Also,
simple inoculations of these animals with tuberculous materials
and cultures of the same had no effect, although they were
tried repeatedly. After the feeding with tuberculous material
had been stopped for several weeks, five of these rats received
intraperitoneal injections with a culture of bacilli (from simian
tuberculosis, cultivated for 142 days). Five weeks later they
were killed and numerous tubercles were found in the lungs, as
well as in the greatly enlarged spleens of these animals. This
experiment is not pure, because the feeding with tuberculous
material had preceded, but I mention it because it was successful
in producing typical tuberculosis, by injection of cultures of
bacilli, in rats, which are only slightly less resistant to all in-
fectious material than dogs.
Experiment II. Of 12 rabbits, 2 received 0.5 cc. of pure blood
serum in the ear vein. Four rabbits received in the same manner,
blood serum with a culture (originating from tuberculosis of
monkeys and cultivated for 178 days); 3 rabbits blood serum
with culture (from phthisical human lungs, cultivated for 103
days); and the 3 last, blood serum with culture (from a lung of
bovine tuberculosis, cultured 121 days). A separate syringe
was used for each of these groups. The first two rabbits re-
mained active and well, all the others rapidly became emaciated
and during the second week, began to breathe with difficulty.
The first animal died after 18 days (injected with culture from
phthisical lung); after 19 days, the second and third (both had
received injections with cultures of simian tuberculosis); after
Etiology of Tuberculosis 873
21 days the fourth (injected with culture of bovine tuberculosis) ;
after 25 days, the fifth (injected with a culture from pulmonary
tuberculosis); after 26 and 27 days, the sixth and seventh (in-
jected with culture of simian tuberculosis) and on the 30th and
31st days, two other animals. The last and the two controls
were killed on the 38th day after the injection.
No difference in the contents of the lungs and other organs
could be made out among the animals infected with the different
cultures. In all animals countless miliary tubercles were found
in the lungs. Also the livers and the spleens of all these animals
contained extraordinarily many tubercles, yet these were only
of microscopic size in those first to die, in those dying later they
had developed so far that they were visible macroscopically, and
in one rabbit miliary tubercles recognizable to the naked eye were
also visible in the omentum, in the diaphragm and in the mes-
entery. The two controls were found to be without tuberculous
deposits anywhere in their organs.
Experiment 12. Two strong, full grown cats each received
(p. 228) an injection in the peritoneal cavity of blood serum
which was mixed with a culture (of simian tuberculosis, cultured
for 162 days). One died after 19 days. The omentum was
infiltrated with thick white material and in some places was over
a centimeter in thickness. The serous surfaces of the intestines
and the peritoneum had lost their sheen, the spleen was markedly
enlarged. The infiltration of the omentum, as in the guinea
pigs that had received intraperitoneal injections of cultures of
bacilli, consisted of thick masses of tubercle bacilli, for the most
part, embedded in cells. Although it had not yet progressed to
a macroscopically recognizable tuberculous eruption, countless
tubercles could be demonstrated microscopically in the lungs,
liver and spleen. The second cat was killed after 43 days and
in this numerous tubercles, the size of millet seeds, were found in
the lungs, spleen and omentum, comparatively few in the liver.
Experiment 13. A bitch several years old was injected intra-
peritoneally with two cc. of blood serum with which a culture
(from human miliary tuberculosis and grown for 94 days) had
been mixed. In the first two weeks after injection no changes
8 74 Medical Classics
were to be observed in the animal, then its spirit was lost, it
ate less and from the end of the third week on, it showed definite
distension of the abdomen. At the beginning of the fifth week
it was killed. A fairly abundant extravasation of clear, pale
yellow fluid was found in the peritoneal cavity. The omentum,
mesentery and broad ligaments contained many tubercles as
did the surfaces of the intestines and bladder. The enlarged
spleen, the liver and lungs contained countless miliary tubercles.
The site of injection could not be recognized and nowhere was
there a trace of caseous pus.
It hardly needs be mentioned that the syringes used in all
these experiments were disinfected by an hour’s heating between
160 and ijo°C. each time before using.
The tubercles obtained by inoculation, as well as by injection
of the cultures of bacilli, were examined microscopically many
times and found to be completely identical with the usual spon-
taneous tubercles or those resulting from the inoculation of
tuberculous material into these animals. They had entirely
the same arrangement of the cellular elements, and very often
contained giant cells which held tubercle bacilli just as those
in the spontaneous tubercles. In addition, the bacilli were
freshly isolated in pure culture from the tubercles obtained by
means of the cultures, and inoculation experiments were set
up with these as well as with the tubercles, all yielding the
same results as inoculation with human or bovine tuberculosis.
In this regard, the tubercles resulting from infection with cultures
were similar to those occurring naturally.
If one looks back over these experiments, it is apparent that
a not inconsiderable number of experimental animals that had
received the cultures of bacilli in various ways, that is, by simple
inoculation into the subcutaneous tissue, through injection into
the abdominal cavity, or into the anterior chamber of the eye or
directly into the blood stream, had been rendered tuberculous
without a single exception; and, indeed, had not developed only
a solitary tubercle but the extraordinary number of tubercles
was proportionate to the large number of infectious germs intro-
duced. In other animals it was possible by the injection of a
Etiology of Tuberculosis 875
minimal number of bacilli into the anterior chamber of the eye,
to produce a tuberculous iritis, as had been done in the well
known experiments of Cohnheim, Salomonsen and Baumgarten
so vital in regard to the question of the inoculation of tuber-
culosis only by true tuberculous material.
A confusion with spontaneous tuberculosis or an accidental
unintentional infection of the experimental animals in these
experiments is excluded on the following grounds. First of all,
neither spontaneous tuberculosis nor an accidental infection can
cause this massive eruption of tubercles in so short a space of
time. Secondly, the control animals which were treated in
exactly the same manner as the infected animals, with the single
difference, that they received no culture of bacilli, remained
healthy. Thirdly, this typical picture of miliary tuberculosis
never occurred in numerous guinea pigs and rabbits injected and
infected in the same way with other substances for other ex-
perimental purposes, as it then only arises when the body is
overcome to a certain extent by a large amount of infectious germs
at one time.
All these facts, taken together, substantiate the claim that
the bacilli present in tuberculous material, not only accompany
the tuberculous process, but are actually the cause of it, and that,
in these bacilli, we have the true virus of tuberculosis.
Thus it is also made possible to delimit w r hat diseases shall be
understood as tuberculosis, which up to now could not be done
with certainty. A definite criterion for tuberculosis was lacking
and one person included miliary tuberculosis, phthisis, scrofula,
bovine tuberculosis, etc., while another, perhaps just as correctly,
regarded all these processes as different. In the future it will
not be difficult to decide what is tuberculous and what is not.
Not the peculiar structure of the tubercles, not the presence of
giant cells, will settle the question, but the demonstration of
tubercle bacilli, whether it be in the tissues by the staining re-
actions or whether it be by culture on solidified blood serum.
Accepting this criterion as standard, miliary tuberculosis, caseous
pneumonia, caseous bronchitis, intestinal and glandular tuber-
culosis, bovine tuberculosis and spontaneous and inoculation
876 Medical Classics
tuberculosis in animals must be declared identical as the result
of my investigations. In regard to scrofula and proliferative
joint affections, my investigations have not been sufficiently
numerous to render judgment. At any rate, a large part of the
scrofulous glands and joint diseases are truly tuberculous. Per-
haps they are all to be considered one with tuberculosis. The
demonstration of tubercle bacilli in the caseous lymph nodes of
a pig, and in the tubercles of a hen, allows us to assume that
tuberculosis has a much larger incidence among the domestic
animals than is generally accepted, and this is worth knowing
in order that we may learn to know the incidence of tuberculosis
in general.
Having established the parasitic nature of tuberculosis, it
must be determined from whence the parasites come and how
they gain entrance to the body, in order to answer completely
the question as to etiology.
In regard to the first question, it is necessary to discover
whether the infectious material will develop only under the
conditions existing in the animal body, or whether it can develop
in any stage free in nature, as, for example, the anthrax bacillus
is independent of the animal organism.
(p. 229) It was now determined by man} r experiments that the
tubercle bacilli grow only in temperatures between 30° and 41 °C.
Below 30°, just as at 4a 0 , the slightest growth did not occur within
three weeks, while anthrax bacilli, for example, grow vigorously
even at co° and between 42 0 and 43°C. On the basis of this
one fact, the questions raised can be decided. In the temperate
climate, with the exception of the animal body, no opportunity
is offered for a uniform temperature of over 3o°C. of at least
two weeks duration. From this it follows, that the tubercle
bacilli must turn to the animal organism exclusively in their
developmental processes; thus, they are not occasional parasites
but true parasites and can arise only from the animal organism.
The second question as to how the parasites enter the body is
also answered. The vast majority of all cases of tuberculosis
have their origin in the respiratory passages and the infectious
material first makes itself manifest in the lungs or in the bronchial
Etiology of Tuberculosis 877
nodes. Thus it is also highly probable that the tubercle bacilli
are usually inhaled with the inspired air, clinging to particles
of dust. There can be no doubt as to the manner in which they
reach the air if one considers in what large quantities the tubercle
bacilli, present in the contents of cavities of patients with pul-
monary tuberculosis, must be expectorated with the sputum
and thus spread all about.
In order to gain some idea as to the presence of tubercle bacilli
in the sputum of phthisical patients, I have examined repeatedly
the sputa from a large series of patients with pulmonary tuber-
culosis and have found that in many of them none is present,
but in about half the cases, they are extraordinarily numerous,
some of them containing spores. As a corollary, it was noted
that, in a number of tests of patients not having phthisis, the
tubercle bacilli were never found. Animals injected with this
fresh sputum containing bacilli became tuberculous just as
surely as after inoculation with miliary tubercles.
Also, when dry, infectious sputa of this sort do not lose their
virulence. Thus, by injection of two weeks old dried sputum,
four guinea pigs were rendered tuberculous, in the same way as
after infection with fresh material, as were four guinea pigs with
sputum kept dry for four weeks and also four more by sputum
kept dry for eight weeks. Accordingly, it can be assumed easily
that on the floor, clothes, etc., dried phthisical sputum retains
its virulence for a long time and if it reaches the lungs in the form
of dust, it can produce tuberculosis. Possibly the retention of
virulence is dependent on the spore formation of the tubercle
bacilli, and it is well to recall in this respect that spore formation,
of which we have seen several examples, takes place within the
animal organism itself, and not outside of it, as is the case with
the anthrax bacilli.
At present, it would lead us too far into the realm of hypothesis
to go into the condition of the acquired or inherited predisposi-
tion, which undoubtedly plays a significant role in the etiology
of tuberculosis. In this respect, more penetrating investigation
is necessary before judgment can be made. I should like to
draw attention to only one point which can serve to explain
878 Medical Classics
many puzzling phenomena and that is the extremely slow growth
of the tubercle bacilli. This is very likely the reason that the
bacilli are not able to infect each and every little wound of the
body, as are the uncommonly rapidly growing anthrax bacilli,
for example. If one wishes to infect an animal with certainty,
then the infectious material must be placed in the subcutaneous
tissue, the peritoneal cavity, or the anterior chamber of the eye,
in short, in some location where the bacilli are able to reproduce
in a protected position and to gain a foothold. Infections of
superficial skin wounds, which do not penetrate into the sub-
cutaneous tissue, or of the cornea, are only occasionally successful.
The bacilli are eliminated before they are able to establish
themselves.
This explains why autopsies on tuberculous bodies do not
lead to infection, even if small cuts on the hands do come into
contact with tuberculous material. Little cuts in the skin are
not suitable inoculation wounds for the entrance of the bacilli.
Similar conditions would also hold in the lungs for the harboring
of inhaled bacilli. It is probably necessary for certain favorable
conditions for the establishing of the bacilli to hold, such as
stagnation of secretions, denudation of the protective epithelium
of the mucous membrane, etc., in order to make infection possible.
Otherwise it would be difficult to understand why tuberculosis
is not much more common than it really is, since every person,
especially in the more densely inhabited areas, comes into more
or less contact with it.
If we now ask what further significance the results obtained
in this investigation of tuberculosis have, then it is to be regarded
as a victory for science that it has been successful, for the first
time, in furnishing complete proof of the parasitic nature of a
human infectious disease; indeed, of the most important one of
all. Up to now such proof had been established only for anthrax,
while for a number of infectious diseases affecting man, for ex-
ample, relapsing fever, wound infection, leprosy, gonorrhea, the
simultaneous presence of the parasite with the pathologic process
was known without being able to prove the causal relationship
between the two. It can be expected that the explanation of
Etiology of Tuberculosis 879
the etiology of tuberculosis will produce new points of view for
the forming of opinions regarding the other infectious diseases,
and that the methods of investigation, which have been used
successfully in seeking out the etiology of tuberculosis, will be
of use in working out the other infectious diseases. This last
may be of special significance for those diseases, which, like
syphilis and glanders, are closely related to tuberculosis and,
together with it form the group of infectious granulomata.
As to how much the knowledge of the properties of the tuber-
culosis parasite will be of value to pathology and surgery, if,
for example, the demonstration of tubercle bacilli in the sputum
can be used for diagnostic purposes, if the certain diagnosis of
many local tuberculous infections will have an influence on their
surgical treatment, and if in some possible manner therapy can
be based on further experiences with the living conditions of
the tubercle bacilli, to judge of all these things, is not my task.
I have undertaken my investigations in the interests of public
health and from them, I hope, the greatest possible benefit
will be derived.
(p. 230) Up to the present it has been customary to regard
tuberculosis as an expression of social poverty, and to hope by
improvement of this to reduce the disease also. On this account,
the public health knew no measures specifically directed against
tuberculosis. But in the future, in the battle with this horrible
plague of the human race, it will be known that we are no longer
dealing with an indefinable Something, but with a definite
parasite whose vital processes are, for the most part, known, and
which can be studied still further. The fact that this parasite
finds its proper living conditions only in the animal body and
can not exist in the outside world under the usual natural con-
ditions, as do the anthrax bacilli, promises a favorable outlook
in the battle with tuberculosis. Thus before anything else, the
sources from which the infectious material flows must be closed
as far as is humanly possible. One of these sources, and cer-
tainly the greatest, is the sputum of consumptive patients, the
disposal of which and the change into a harmless state of which,
U P to the present have not received sufficient care. It can not
880 Medical Classics
be reckoned as extremely difficult to render phthisical sputum
harmless by disinfection, and thus cut off the greatest part of
the infectious tuberculous material. Also, the disinfection of
the clothes, beds, etc., which are used by tuberculous patients
should receive consideration.
Tuberculosis of domestic animals, especially bovine tuber-
culosis, undoubtedly forms another source of infection. The
position is indicated as to what stand public health should take
in the future on the question of the danger of the meat and milk
of animals with bovine tuberculosis. Bovine tuberculosis is
identical with the tuberculosis of man, and thus it is a disease
which is transmissable to man. Therefore, it is to be treated
exactly as any other infectious disease of animals which can be
carried to man. Thus ’though the danger resulting from the
flesh or milk of bovine tuberculosis be great or small, nevertheless
it is present and must be avoided. It has long been known that
anthrax meat is eaten by many people, and often over a long
period of time, without any ill effects, and yet no one would
draw the conclusion from this that the trade in such meat should
be permitted.
In regard to the milk of tuberculous cows, it is noteworthy
that frequently involvement of the mammary glands by the
tuberculous process has been observed by veterinarians, and it is
therefore easily possible that in such cases the tubercle virus
can be mixed directly with the milk.
A number of other points in regard to regulations which, on
the basis of our present knowledge of the etiology of tuberculosis,
might serve to limit the disease may be mentioned, but a dis-
cussion of these would lead too far at the present time. If the
conviction that tuberculosis is an exquisite infectious disease
makes its way among the doctors, then the question of a pur-
poseful attack on tuberculosis certainly will come under discussion
and it will develop of itself.
MEDICAL CLASSICS
VOL. 2 May, 1938 NO. 9
CONTENTS
Portrait of Sir Benjamin Collins Brodie - - - 882
Biography ----------- - 883
Eponyms - -- -- -- -- -- - 885
Bibliography of Writings ------- 885
Biographies - -- -- -- -- -- 893
Index to Bibliography - -- -- -- - 894
Brodie’s Abscess: An Account of Some Cases of
Chronic Abscess of the Tibia. B. C. Brodie,
F.R.S. __-- 9 oo
Brodie’s Abscess: Lecture on Abscess of the Tibia.
Sir B. C. Brodie, Bart. ------- - 907
Brodie’s Disease of Joints. B. C. Brodie, Esq.,
F.R.S. - - - 9 l 9
Brodie’s Pile. Sir B. C. Brodie, Bart. - - - - 929
Brodie’s Tumor. Sir Benjamin Brodie, Bart. - - 941
MEDICAL CLASSICS
vol. i ■ May, 1938 no. 9 '
Sir Benjamin Collins Brodie
BIOGRAPHY
1783 Born, son of a clergyman, in Winterslow, in Wiltshire,
who was descended from a Jacobite exile in England.
1801 Age 18. Sent to London to study medicine; attended
anatomical lectures given by Abernethy at St. Barthol-
omew’s Hospital and by James Wilson at the Great
Windmill Street School of Medicine.
1803 Age 20. Pupil of Sir Everard Home, Surgeon to St.
George’s Hospital.
1805 Age 22. House Surgeon at St. George’s from May until
November, then became assistant to Dr. Home. Lec-
tured at Great Windmill Street until 1812.
1808 Age 25. Became assistant surgeon to St. George’s Hos-
pital and lectured there until 1840. Influenced by
Bichat, at first devoted himself to physiologic experi-
mentation.
1809 Age 26. Opened office in Sackville Street.
1810 Age 27. Elected Fellow of the Royal Society.
1811 Age 28. Won Copley Medal for two papers on influence
of nervous system on production of animal heat. Gave
the Croonian lecture.
1813 Age 30. Described disease of joints now called by his
name.
1816 Age 33. Married Miss Sellon; three children survived
the parents
1819 Age 36. Moved into larger house in better district be-
cause of increasing practice. Succeeded William
Lawrence as Professor of Comparative Anatomy and
883
884 Medical Classics
Physiology at The Royal College of Surgeons— held
post until 1823.
1822 Age 39. Became full Surgeon at St. George’s.
1828 Age 45. Surgeon to King George IV.
1832 Age 49. Serjeant Surgeon to William IV. Described
Abscess of Bones, (Brodie’s Abscess).
1834 Age 51. Became Member of Council of Royal College of
Surgeons of England and Member of Court of Exam-
iners because of attendance on King. Raised to rank
of Baronet.
1840 Age 57. Resigned as Surgeon to St. George’s Hospital.
Described Sero-Cystic Tumour of Breast, (Brodie’s
Tumour).
1844 Age 61. Elected President of The Royal College of
Surgeons, England
1858 Age 75. First President of General Medical Council
until i860. President of the Royal Society until 1861.
Later suffered from double cataract for which he was
operated on by Sir William Bowman.
1862 Age 79. October 21, died at his home, Broome Park,
Surrey, of a painful disease of the shoulder.
Also; Member of National Association for the Promotion of
Social Science.
D. C. L., Oxford.
President of Royal Medical and Chirurgical Society.
Member of Institute of France.
Member of Academy of Medicine of Paris.
Member of Royal Academy of Sciences of Stockholm.
Member of National Institution of Washington.
Brodie’s personal appearance is thus described by Mr. Holmes
who knew him personally in his latter years;
“Keen grey eyes, a noble and sensitive mouth and facial mus-
cles which followed all the movements of one of the most active
of minds, lent to the countenance a charm and an impressiveness
to which no stranger could be insensible. His frame was slight
Sir Benjamin Collins Brodie 885
and small; but there was nothing of weakness in it, and its move-
ments were vigorous and even brusque, such as are habitual to a
man whose whole life is passed in constant activity.”
EPONYMS
1. Abscess: A chronic inflammation and ulceration, sometimes
tuberculous, of bone, especially in the head of the tibia.
2. Bursa: Beneath the semimembranous and the inner head
of the gastrocnemius muscles.
3. Disease of Joints: Chronic synovitis, especially of the knee
joint, in which the affected parts acquire a soft and putty
consistence.
4. Disease of Spine: Hysteric pseudo-fracture.
5. Joint: See knee.
6. Knee: Chronic synovitis of the knee joint.
7. Operation: For fissure or ulcer of anus, the muscle fibers
of the sphincter being divided at one side by a history
drawn from the anus laterally outward.
8. Pain: That induced by folding the skin near a joint affected
with neuralgia.
9. Pile: Sentinel pile — a mass of inflamed and traumatized
anal mucosa at the lower end of a fissure-in-ano.
10. Tumor: Serocystic tumor of the breast; cystadenoma or
chronic systic mastitis.
BIBLIOGRAPHY OF WRITINGS
A — Army Medical Library.
B — New York State Library.
C — New York Academy of Medicine Library.
D — Kings County Medical Society, Brooklyn, Library.
E — Lane Medical Library of Stanford University.
1. Account of the dissection of a human fetus in which the cir-
culation ( of the blood was carried on without a heart.
Phil. Trans., 161-168, 1809. Also: Reil, Archiv., 12:
393-403, 181 5. . , . . ,
2. On some physiological researches respecting the influence or
the brain on the action of the heart, and on the generation
886 Medical Classics
of animal heat. Phil. Trans., ioi: 36-48, 1811. Also:
London, W. Bulmer & Co., 1811. Roy. 8°, 15 pp. Also:
Brugnatelli, Giornale, 5* 129— 142, 1812. Also: Reil,
Archiv., 12: 137-155, 18x5. (Same), London, Longman,
1851. 8°, vi, 146 pp., 1 pi. In A, C and D.
3. Experiments and observations on the different modes in
which death is produced by certain vegetable poisons.
Phil. Trans., 101s 178-208, 1811. Also: London, W.
Bulmer & Co., 1811. 4 0 , 31 pp. In A. Also: Bull, de
Phar., 55: 169-178, 1812. Also: Reil, Archiv., 12: 156-
198, 1815.
4. Further experiments and observations on the action of poisons
on the animal system. Phil. Trans., 205-227, 1812. Also:
Annal. de Chimie, 92: 5-31, 1815. Also: Reil, Archiv.,
12: 223-254, 1815.
5. Further experiments and observations on the influence of
the brain on the generation of animal heat, Phil. Trans.,
378-393, 1812. Also: Jour, de Phys., 76: 386-387, 1813.
Also: Nicholson, Jour., 34: 199-211, 1813. Also: Gilbert,
Annalen, 46: 80-93, 1814. Also: Reil, Archiv., 12: 199-
222, 1815.
6. On abscess in the brain. Trans. Soc. for Improvement of
Med. & Chir. Knowledge, 1812.
7. Pathological researches respecting the diseases of joints.
Med.-Chir. Trans., 4: 207-277, 1813.
8. The Croonian lecture for 1813. On the influence of the
nervous system on the action of the muscles in general
and of the heart in particular. (Printed from the Archives
of the Royal Society, Works of Sir. B. C. Brodie, ed. by
C. Hawkins.) Lond., 2: 97, 1865.
9. Experiments and observations on the influence of the nerves
of the eighth pair on the secretions of the stomach. Phil.
Trans., 102-106, 1814.
10, Further observations on the diseases which affect the synovial
membranes of joints. Med.-Chir. Trans., 5: 239-254,
1814.
11. Case of ununited fracture of the femur successfully treated
by the introduction of a seton. Ibid., 387.
Sir Benjamin Collins Brodie 887
12. Further observations on the ulceration of the cartilages of
joints. Ibid., 6: 318, 1815.
13. Observations on the treatment of varicose veins of the leg.
Ibid., 7: 195, 1816.
14. Pathological and surgical observations on diseases of the
joints. London, Longman, 1818. 8°, vii, 329 pp. In
A. C. D and E.
(Same) Traite des maladies des articulations. Trans. by-
Leon Marchand. Paris, Plancher, 1819. 8°, xvi, 248 pp.
In A.
(Same) Philadelphia, Warner, 1821. 8°, vii, 329 pp., 6 pi.
In A, C, D and E.
(Same) Pathologische und Chirurgische Beobachtungen iiber
die Krankheiten der Gelenke. Trans, with notes and
additions by G. P. Holscher. Hannover, Hahn, 1821.
8°, xvi, 400 pp. 1 1., 6 pi., (2 col’d.). In A and C.
(Same) 2. ed., London, Longman, 1822. 8°, vii, 376 pp.,
8 pi. In A and C.
(Same) Over de ziekten der gewrichen. Trans, with notes
and additions by Hend. Sim. Hijmans. Haarlem, bij de
Wed. A. Loosjes, Pz., 1823. 8°, viii, 317 pp. In A.
(Same) 3. ed., London, 1834. In E.
(Same) 3. ed., Washington, Green, 1834. 8°, vii, 13 1 pp.
In A, C, D and E.
(Same) 4. ed., London, Longman, 1836. 8°, xi, 354 pp.
In C and D.
(Same) From 4. London ed., Boston, Marvin, 1842. 8°,
viii, 343 pp. In A, B, C, D and E.
(Same) Philadelphia, Lea and Blanchard 1843. 8°, 216 pp.
In A, C, D and E.
(Same) From 4. London ed., Philadelphia, Lea and
Blanchard,' 1847. In D.
(Same) 5. ed., 1850. 8°, vii, 349 pp. In A, B, C, D and E.
(Same) Abhandlung iiber die Krankheiten der Gelenke.
(Translated from the enlarged 5- English ed. and aug-
mented by an appendix including the experiences of
German and French surgeons, completed by G. A Soer.)
Coblenz, Holscher, 1853. 8°, vii, 400 pp. In A.
888 Medical Classics
15. Introductory lecture — Royal College of Surgeons. London,
Burgess and Hill, 1820. 8°, 2 p. 1., 50 pp. In A and C.
16. Observations on the effects produced by the bile in the
process of digestion. Quart. Jour. Sc., 14: 341-344, 1823.
Also: Froriep, Notizen, 4: Col. 177-180, 1823. Also:
Magendie, Jour, de Phys. 3: 93~94 j ^23.
17. Diseases of the urethra, bladder and prostate bland. Lon-
don Med. Gaz., 1:4-8; 49-53, 1827; (stricture) 105-110;
169-173; 233-237; (irritable bladder) 297-301; (prostate)
393-397; 457-460; (treatment of chronic enlargement of
prostate gland) 521-525.
18. Pathological and surgical observations relating to injuries
of the brain. Med.-Chir. Trans., 14: 325, 1828.
19. Experiments and observations intended to explain the mode
in which death is produced by lightning. Lond. Med.
Gaz., i: 79-81, 1828.
20. Needles extracted from various parts of the body. Ibid.,
148-149.
ai. Cysts containing watery fluid, apparently connected with the
liver. Ibid., 334-335.
22. On trephining the tibia. Ibid., 2:70-74.
23. Injuries of the brain. Ibid., 134-139; 199-205; 230-235;
297-302; 357-363.
24. Peculiar affection of the wrist, occurring in hysterical pa-
tients. Ibid., 755-756.
25. Clinical lecture on effusion of urine. Ibid., 3: 25-27, 1829.
26. Case of aneurysm by anastomosis of the forehead treated by
the application of ligatures. Med.-Chir. Trans., 15: 177,
1829.
27. On conduct and duties of medical practitioner. Lond. Med.
Gaz. 5:39-45, 1829.
28. Observations on certain local nervous affections. Ibid.,
553~5 6 2> 1830.
29. Use of iodine in morbid growths. Ibid., 750-751.
30. Observations on calculus diseases. Ibid., 8: 1-8, 1831.
(renal calculi) 65-71; (calculi of bladder) 129-137; 225-
22 9i 353-35 8 ; (operation of lithotomy) 609-616; 833-842.
Sir Benjamin Collins Brodie 889
31. An account of some cases of chronic abscess of the tibia.
Med.-Chir. Trans. 17: 239-249, 1832.
32. Brief account of ligature of subclavian artery. Lond. Med.
Gaz., 9 : 395 - 396 , 1832.
33. Account of a clinical lecture on hydrocele and hematocele.
Ibid., 926-929.
34. Case of amputation at the shoulder joint. Ibid., ii: 300-
303, 1833.
35. Lectures on diseases of the urinary organs. London, Long-
man, 1832. 8°, viii, 306 pp. In A and C.
(Same) Vorlesungen fiber die Krankheiten der Harnmerk-
zeuge. Weinar, 1833. 8°, vi, 150 pp., pi. In A and C.
(Same) 2. ed., London, Longman, 1853. 8°, viii, 329 pp.
In C and D.
(Same) Vorlesungen fiber die vorzfiglichsten Krankheiten
der Harnausffihungsorgane. Leipzig, 1836. 8°, In A.
(Same) 3. ed. London, Longman, 1842. 8°, vii, 379 pp.
In A and D.
(Same) From 3. London ed., Philadelphia, Lea and Blanch-
ard, 1843. 8°, 214 pp. In A, B, C, D and E.
(Same) 2. Amer. from last London ed., Philadelphia, Lea and
Blanchard, 1847. I n ® and E.
(Same) 4. ed., London, Longman, 1849. 8°, vii, 392 pp.
In A, C and E.
(Same) Translated into French by Patron, Montpellier.
36. Ununited fractures. Lond. Med. Gaz., 13: 53— 59a 1 833-
37* Diseases of the testicle. Ibid., (hydrocele) 88-94; 136-140;
(inflammation) 218-223; (tuberculosis) 377 _ 38 2 ; (fungus
hematodes) 407-410; 618-622.
38. Clinical observations on ununited fractures. Ibid., 14:
616-61 8, 1834.
39 * Clinical observations on fatty tumors. Ibid., 679-681.
40. On encysted tumors. Ibid. 15: 2 5 -2 7 > 1 835*
41. On diseases of the maxillary antrum. Ibid., 34 ^- 35 I *
42. On hemorrhoids. Ibid., 742-747; (prolapsus) 842-847.
43 - On diseases of rectum, cont’d., (preternatural contraction of
sphincter ani). Ibid., 16: 26-31; 236-239, 1835.
8oo Medical Classics
t - Diseases of rectum, cant'd., (abscesses, fistula). Ibid., 17*.
26-29: 485— 490: 38; 382—1 87, 3,835*
49. Outline of paper on pathological and surgical observations to
injuries of spinal cord- Ibid-, 379-381.
46. On tic douloreaux or facial neuralgia. Ibid., 534~539-
47. A case of compound fracture of tibia followed by traumatic
delirium- Ibid., 623-636.
48. On corns and bunions. Ibid., 775"7^°'
40- On local hysterica! affections. Ibid., 29: 197-202; 246-250;
__ 279-286, 2S37.
50. imtracts from Hunterian Oration. Ibid-, 969-972.
52. The Hunterian oration, 2837. London, Longman, 2837.
S~. 3® pp. in A.
52. Lectures illustrative of certain local nervous affections.
London, Longman, 2837. 8°, iv, 88 pp. In A B, C,
D and E.
(Same) in Dunghson’s Amer. hied. Library, Philadelphia,
^1838. _ pp. 33-74-
(Same) Tcrlesnngen fiber ordiche Nerrenleiden. Aus dem
Englischen von Dr- Kurschner. Marburg, Garthe, 1838.
8°, iv, 65 pp. In A.
53. Pathological and surgical observations relating to injuries of
the spinal cord. MecL-Chir. Trans., 20: 218, 2837. Also:
m Dnnghson’s Amer. hied. Library, Philadelphia 2838,
^ PP* 45 3 747A
54. An introductory discourse on the studies required for the
medical profession. London, Brettell, 2838. 8°, 32 pp.
In A.
55- On diseases of the kidney. Lond. hied- Gaz., 22: 206—209,
-rR-iP *
56. On varicose veins and ulcers of the legs. Ibid., 184-289;
264—263..
57. On sero-cystic tumors of the breast Ibid., 25: 808-824,
22 J4j ortm cat5 on- 2'y c 47 536—5,* 3.0 j
tOi— 5ob; 745~7 5°3 3842- (hospital gangrene) 633-636;
(senile gangrene) 714-729.
Sir Benjamin Collins Brodie 891
59. An account of two cases of imperforate hymen. (Review).
Ibid., 8 10-81 1.
60. Eulogium on Sir Astley Cooper, delivered at a meeting of the
Royal Medical and Chirurgical Society. Lond. Med.
Gaz., 27: 884-886, 1841.
61. Lectures illustrative of some important circumstances con-
nected with operative surgery. Ibid., 31: 388-393; 641-
648, 1 842.
62. On quacks and quackery. 1842.
63. Clinical lectures on surgery. Med. News and Library, vol.
1 - 3 > 1843-1845- _
64. An introductory discourse on the duties and conduct of
medical students and practitioners. Lond. Med. Gaz.,
33; 97-105, 1843. Also: London, Mitchell, 1843. 8°,
34 pp. In A and C.
(Same) Over de pligten en den levenswandel van studenten
in de medicijnen en jeugdige geneesheeren. Vertaald door
Rudolf Ruben. Amersfoort, W. J. van Bommel van
Vloten, 1844. 8°, 33 pp. In A.
65. Brief report of a case in which a foreign body was lodged in
the right bronchus. Lond. Med. Gaz., 32: 540-541; 33:
215-216, 1843.
66. Abscess and fistula connected with the rectum. Ibid., 33:
515-521; 554-558; 584-589, 1844.
67. Cases in which it is expedient to perform the operation for
the removal of scirrhous tumor of the female breast. Ibid.,
628-833; continued, with administration of mercury in
cases of syphilis. Ibid., 664-671.
68. Some diseases of the breast. Med. Times, 10: 163, 1844.
69. Lecture on abscess of the tibia. Lond. Med. Gaz., 36:
1399-1403, 1845.
7 Lectures on diseases of the knee joint. Ibid., 37- 221-225;
397-402; 489-493; 623-627, 1846.
7 1 - Discourse on the mode of investigating the sciences belonging
to the medical profession. Ibid., 38: 603-613.
72. Lectures on distortion of the spine not connected with
caries. Ibid., 999-1003; 39: 1-6; 89-93.
892 Medical Classics
73. Clinical lectures on surgery, delivered at St. George’s Hos-
pital. Philadelphia, Lea and Blanchard, 1846. 8°, viii,
352 pp. In A, B, C, D and E.
74. Lectures illustrative of various subjects in pathology and
surgery. London, Longman, 1846. 8°, vii, 411 pp. In
A, C and D.
75. Chemical relations of wax and fat. Lond. Med. Gaz., 53:
474 ~ 475 > i 8 49 *
76. Address at the Ethnological Society of London, delivered
at the annual meeting on the 26th of May, 1854. London,
Watts, 1854. 8°, 25 pp. In A.
77. Psychological inquiries: mind and matter: in a series of
essays, intended to illustrate the mutual relations of the
physical organization and the mental faculties. 2. ed.,
London, Longman, 1855. 12 0 , xii, 275 pp. In A, C and
D. (1. ed., 1854, anonymous.)
(Same) With additional notes by an American editor. New
York, Putnam, 1857. 12 0 , viii, 279 pp. In A, C,DandE.
(Same) New York, Wood, 1858. 8°, viii, 279 pp. In A and
D.
(Same) The second part being a series of essays intended to
illustrate some points in the physical and moral history of
man. London, 1862. 12 0 , xi, 247 pp. In C and E.
(Same) New York, Wood, 1873. In D.
78. Notes on lithotrity, with an account of the results of the
operation in the author’s practice. Med.-Chir. Trans.,
38: 169, 1855.
79. Case of myeloid (?) tumour of bone. (Notice) Ibid., 39:
122, 1856.
80. The healing art the right hand of the church: or practical
medicine an essential element in the Christian system.
By Therapeuts. Edinburgh, Sutherland & Knox, 1859.
8°, 3 p. 1., 280 pp. In A.
81. President’s address delivered at the anniversary meeting of
the Royal Society, Nov. 30, 1859. London, Taylor &
Francis, 1859. 8 °> 20 PP- I n A.
82. The use and abuse of tobacco. (London, i860) 8°, 16 pp.
In A.
Sir Benjamin Collins Brodie 893
83. Notice on a case of calculus, mixed with teeth, hair, etc.
Med.-Chir. Trans., 43: 109, i860.
84. Homeopathy: a letter to J. S. S., Esq. London, Parker, 1S61.
8°, 8 pp. In A.
85. Letter on Dr. Bullar’s case of pulsating bronchocele. Med.-
Chir. Trans., 44: 38, 1861.
86. Letter on Dr. Water’s paper on asphyxia and the use of the
hot bath. Ibid., 149.
87. The works of Sir Benjamin Collins Brodie with an auto-
biography. Collected and arranged by Charles Hawkins.
London, Longman, 1865. 8°, 3 vols. In A. C, D and E.
BIOGRAPHIES
Biography by Pettigrew. Med. Port. Gallery, II, vol. 5, 1 6 pp.,
London, 1840.
Biography. Lancet, 1: 538-544, 1850.
The medical case of Sir Benjamin Brodie; the operation on his
eyes. Boston Med. & Surg. Jour., 62: 467, 1861.
Biography. Lancet, 2 : 452-457, 1862.
Biography. Med. Times & Gaz., 2: 452; 474; 504, 1862.
Biography. Wien. med. Woch., 12: 732; 748, 1862.
Biography by Giraldes. Bull. Soc. de Chir. de Paris, 3: 606-
631, 1863.
Biography by H. W. Acland. London, 1864. 12°, 31 pp.
Autobiography. (With The Works of Sir Benjamin Collins
Brodie, collected and arranged by Charles Hawkins.) Lon-
don, Longman, 1865. 8°, 3 vols.
Biography by J. Althaus. Deutsche Klinik, 18: 241; 253, 1866.
Biography by R. E. Thompson. Diet. Nat. Biog., 6: 378-380,
1886.
Masters of medicine: Benjamin Brodie. By T. Holmes. Lon-
don, Unwin, 1898. 8 , 256 pp.
Biography. Practitioner, 61: 381-387, 1S98.
Biography. Boston Med. & Surg. Jour., 140: 369-373, 1899.
Biography. Brit. Jour. Surg., 6: 157 -I 59> I 9 1 ^*
Brodie’s tumor and Brodie’s abscess: eponyms. By Sir D A.
Power. Brit. Jour. Surg., 9: 334~337> 1 9--*
Sketch. Lancet, 2: 709, 1923.
892 Medical Classics
73. Clinical lectures on surgery, delivered at St. George’s Hos-
pital. Philadelphia, Lea and Blanchard, 1846. 8°, viii,
352 pp. In A, B, C, D and E.
74. Lectures illustrative of various subjects in pathology and
surgery. London, Longman, 1846. 8°, vii, 411 pp. In
A, C and D.
75. Chemical relations of wax and fat. Lond. Med. Gaz., 53:
474 47 5 * 1 849-
76. Address at the Ethnological Society of London, delivered
at the annual meeting on the 26th of May, 1854- London,
Watts, 1854. 8°, 25 pp. In A.
77. Psychological inquiries: mind and matter: in a series of
essays, intended to illustrate the mutual relations of the
physical organization and the mental faculties. 2. ed.,
London, Longman, 1855. 12°, xii, 275 pp. In A, C and
D. (1. ed., 1854, anonymous.)
(Same) With additional notes by an American editor. New
York, Putnam, 1857. 1 2°, viii, 279 pp. In A, C, D and E.
(Same) New York, Wood, 1858. 8°, viii, 279 pp. In A and
D.
(Same) The second part being a series of essays intended to
illustrate some points in the physical and moral history of
man. London, 1862. 12 0 , xi, 247 pp. In C and E.
(Same) New York, Wood, 1873. In D.
78. Notes on lithotrity, with an account of the results of the
operation in the author’s practice. Med.-Chir. Trans.,
38: 169, 1855.
7 9. Case of myeloid (?) tumour of bone. (Notice) Ibid., 39:
122, 1856.
80. The healing art the right hand of the church: or practical
medicine an essential element in the Christian system.
By Therapeuts. Edinburgh, Sutherland & Knox, 1859.
8°, 3 p. 1., 280 pp. In A.
81. President’s address delivered at the anniversary meeting of
the Royal Society, Nov. 30, 1859. London, Taylor &
Francis, 1859. 8°, 20 pp. In A.
82. The use and abuse of tobacco. (London, i860) 8°, 16 pp.
In A.
Sir Benjamin Collins Brodie 893
83. Notice on a case of calculus, mixed with teeth, hair, etc.
Med.-Chir. Trans., 43: log, i860.
84. Homeopathy: a letter to J. S. S., Esq. London, Parker, 1861.
8°, 8 pp. In A.
85. Letter on Dr. Bullar’s case of pulsating bronchocele. Med.-
Chir. Trans., 44:38, 1861.
86. Letter on Dr. Water’s paper on asphyxia and the use of the
hot bath. Ibid., 149.
87. The works of Sir Benjamin Collins Brodie with an auto-
biography. Collected and arranged by Charles Hawkins.
London, Longman, 1 865. 8°, 3 vols. In A. C, D and E.
BIOGRAPHIES
Biography by Pettigrew. Med. Port. Gallery, II, vol. 5, 16 pp.,
London, 1840.
Biography. Lancet, 1: 538-544, 1850.
The medical case of Sir Benjamin Brodie; the operation on his
eyes. Boston Med. & Surg. Jour., 62: 467, 1861.
Biography. Lancet, 2: 452-457, 1862.
Biography. Med. Times & Gaz., 2: 452; 474; 504, 1862.
Biography. Wien. med. Woch., 12: 732; 748, 1862.
Biography by Giraldes. Bull. Soc. de Chir. de Paris, 3: 606-
631, 1863.
Biography by H. W. Acland. London, 1864. 12°, 31 pp.
Autobiography. (With The Works of Sir Benjamin Collins
Brodie, collected and arranged by Charles Hawkins.) Lon-
don, Longman, 1865. 8°, 3 vols.
Biography by J. A 1 thaus. Deutsche Klinik, 18: 241; 253, 1866.
Biography by R. E. Thompson. Diet. Nat. Biog., 6: 378-380,
1886.
Masters of medicine: Benjamin Brodie. By T. Holmes. Lon-
don, Unwin, 1898. 8 , 256 pp.
Biography. Practitioner, 61:381-387, 1898.
Biography. Boston Med. & Surg. Jour., 140: 369-373, 1899.
Biography. Brit. Jour. Surg., 6: I 57 “ I 59 > J 9 l8 -
Brodie’s tumor and Brodie’s abscess: eponyms. By Sir DA.
Power. Brit. Jour. Surg., 9: 334 - 337 > 1 9 22 -
Sketch. Lancet, 2: 709, 1923.
894 Medical Classics
Biographical sketch. New England Jour. Med., 203: 749~75 °j
1 930-
Biography by H. E. Mansell. Lancet, 2: 408-419, 1935.
INDEX TO BIBLIOGRAPHY
References Year
Abscess, brain 6 1812
“ rectum 44 *836
66 1844
“ tibia 31 1832
69 1845
Amputation, shoulder 34 1832
Aneurysm, forehead 16 1829
Antrum, maxillary, diseases of 41 1835
Artery, subclavian, ligature 32 1832
Autobiography 87 1865
Bile in digestion 16 1823
Bladder, calculi 30 1829
“ diseases of 17 1827
Blood, circulation of 1 1809
Bone tumor 79 1856
Brain, abscess 6 1812
“ action of heart on 2 1811
“ injury 18, 22 1828
Breast diseases 68 1844
“ tumors 57 1840
67 1844
Bronchus, foreign body in 65 1843
Bullar’s, Dr., case 85 1861
Bunions 48 1 836
Calculus diseases 30 1829
Caries of spine 72 1846
Cartilages of joints 12 1815
Cooper, Sir Astley 60 1840
Corns 48 1836
Croonian lecture 8 1813
Delirium, traumatic 47 1836
Sir Benjamin
Collins Brodie
8 9S
References
Year
Digestion, bile in
16
1823
Ethnological address
76
1854
Facial neuralgia
46
1836
Fat, and wax
75
1849
Fatty tumors
39
1834
Femur, fracture
II
1814
Fistula, rectal
44
1836
66
1844
Fracture, ununited
II
1814
36
!833
38
1834
Fungus hematodes
37
i8 33
Gangrene, hospital and senile. .
58
1840
Healing Art
80
1859
Heart, absence of
I
1809
“ influenced bv brain
2
1811
8
1813
Heat, animal
2
1811
5
1812
Hematocele
33
1832
Hemorrhoids
42
1835
Homeopathy
84
1861
Hunterian oration
5°>5 I
1837
Hydrocele
33
1832
37
1833
Hymen, imperforate
59
1840
Hysterical affections
1837
Iodine in morbid growths
2 9
1829
Joints, diseases of
7
1813
10
1814
12
1815
1818
<c knpp
1846
Kidney, diseases of
1838
Lightning causing death
1828
Lithotomy
1829
896 Medical Classics
References Year
Lithotrity 7 8 l8 55
Liver, cyst 21 i8 28
Medical practitioner 2 7 i82 9
64 1843
" profession 54 i8 3 8
“ sciences 7 1 1846
“ -studies 54 i8 3 8
Mercury in syphilis 67 1844
Mortification 5 8 1840
Muscles, action of 8 1813
Myeloid tumor 79 i8 56
Nerves, eighth pair 9 1814
Nervous affections 28 1829
52 1837
“ system 8 1813
Neuralgia, facial 46 1836
Pathology 74 1846
Poisons 3 1 81 1
4 1812
Prostate, diseases of 17 1827
Psychological inquiries 77 1855
Quackery 62 1842
Rectum, diseases of 43 1835
44 1836
66 1844
“ prolapsus 42 1835
Renal calculi 30 1829
Royal College of Surgeons, address 15 1820
81 1859
Shoulder, amputation of 34 1832
Sphincter ani 43 1835
Spinal cord, injuries of 45 1836
53 i8 37
Spine, distortion of 72 1846
Stomach, secretions of 9 1814
Subclavian artery, ligature 32 1832
Sir Benjamin Collins Brodie
897
References Year
Surgery 61 184a
63 1843
73, 74 1846
Synovial membranes 10 1814
Syphilis, mercury in 67 1844
Testicle, diseases of 37 1833
Tibia, abscess 31 1832
69 1845
“ fracture 47 1836
“ trephining 22 1828
Tic douloreaux 46 1836
Tobacco 82 i860
Tumors, breast 57 1840
67 1844
“ encysted 40 1835
“ fatty 39 1834
“ myeloid 79 1856
Ulcers, legs 56 1838
Urethra, diseases of 17 1827
Urinary organs, diseases of 35 I ^3 2
Urine, effusion 25 1828
Varicose veins 13 1816
56 1838
Water’s, Dr., paper 86 1861
Wax and fat 75 x ^49
Wrist, affection 24 1828
INTRODUCTION
Benjamin Collins Brodie obtained for his day an excellent
medical education. In London he studied anatomy under
Abernethy at St. Bartholomew’s Hospital and also worked under
James Wilson at the Great Windmill Street School of Medicine.
At the age of twenty he was a pupil of Sir Everard Home at St.
George’s Hospital and two years later became House Surgeon
there. Dr. Home then employed Brodie as his assistant and at
the age of twenty-five we find Brodie actively at work at St.
George’s Hospital as Assistant Surgeon.
The very next year, in 1809, at the age of twenty-six we find
Brode publishing his first paper. Account of the dissection of a
human fetus in which the circulation of the blood was carried on
without a heart.
In 1 81 1 he published two papers, the first on the influence of
the brain on the action of the heart and the second on the effects
of certain vegetable poisons. In the following year he wrote on
the influence of the nervous system on the production of animal
heat and in 1813 he first described a disease of joints which is now
called by his name.
Benjamin Brodie rapidly rose in the medical world and at the
age of thirty-six became Professor of Comparative Anatomy and
Physiology at the Royal College of Surgeons. At the age of
thirty-nine he became full surgeon at St. George’s Hospital. In
1828 at the age of forty-five, he was appointed surgeon to King
George IV and four years later Serjeant-Surgeon to William IV.
In this same year, 1832, he published a paper, An account of
some cases of chro?iic abscess of tibia. For a long time he had been
particularly interested in diseases of bones and joints, fourteen
years previously having written a book on Pathological and surgical
observations on diseases of the joints which went through five edi-
tions and was translated into French, German and Dutch.
The paper of 1832 is reproduced on the following pages as it was
first printed; it is in reality a series of case reports which jBrodie
had collected from his experience as surgeon to St. George’s
Hospital. Case I concerns a young man who died following an
amputation of the leg for a chronic osteomyelitis of twelve years
duration. Without the aid of x-rays, Brodie was unable to foresee
an abscess within the tibia. After amputation and the fatal
outcome he determined at his next opportunity to trephine the
bone and probably save both life and limb. A year and a half
later, however, Brodie frankly admits that a second case was
treated by a simple incision through the periosteum. Almost two
years later it became necessary to again operate on this patient
and this time Brodie trephined the bone abscess and was rewarded
with a cure. The third patient benefited by the experiences with
the other two, was operated on by trephining the bone and re-
covered.
In 1834 at the age of fifty-one, Brodie was raised to the rank of
Baronet.
In 1835 he delivered a series of lectures on diseases of the rectum
at St. George's Hospital. Lecture number three treated of pre-
ternatural contraction of the sphincter ani. This paper is repro-
duced on the following pages in its complete and original form.
The work shows a great interest in the subject of rectal disease
and a wide knowledge of rectal pathology. Brodie described a
pathologic finding which has become known as Brodie’s pile and
also an operation for fissure or ulcer of anus which is still known
by his name. The paper is important because it reveals the
teaching of a hundred years ago of this famous surgeon and
describes a condition and an operation which are still known and
used today.
The last paper of Sir William Collins Brodie which is reproduced
here is a Lecture on sero-cystic tumors of the breast delivered at St.
George's Hospital in 1840. The subject was chosen by Brodie
because he had attended many patients with the condition and
because he felt his experience would be helpful to the younger
practitioners. He promptly states in the second paragraph that
he is not describing a new disease. Sir Astley Cooper and M.
Velpeau both having written on the subject. But Brodie s
description of the clinical manifestations and gross pathology are
so clear and exact that the condition to this day is called Brodie s
tumor. The paper is an important one in the progress of knowl-
edge of diseases of the breast.
Late in life Sir William Collins Brodie was elected president
of the Royal College of Surgeons, of the General Medical Council
and of the Royal Society. He was acknowledged leader of the
medical profession of London and it is fitting that his name is
remembered by numerous medical eponyms.
Brodie’s Abscess
An Account of Some Cases of Chronic
Abscess of the Tibia
BY
B. C. BRODIE, F. R. S.
Surgeon to St. George’s Hospital
Read March 27th, 1832. Published in Medico-Chirurgical Transactions, London, 17:
239-249, 1832
AM not aware that any cases exactly similar to
those which I am about to relate have been
recorded by authors: and as they appear to me
to throw some light on the history and treat-
ment of a rare but very serious disease, I am
led to believe that they are not unworthy of
being communicated to the Medical and Chirurgical Society.
case 1
Mr. P., about twenty-four years of age, consulted me in
October, 1824, under the following circumstances.
There was a considerable enlargement of the lower extremity of
the right tibia, extending to the distance of two or three inches
from the ankle-joint. The integuments at this part were tense,
and they adhered closely to the surface of the bone.
(p. 240) The patient complained of a constant pain referred
to the enlarged bone, and neighbouring parts. The pain was
always sufficiently distressing; but he was also liable to more
severe paroxysms in which his sufferings were described as most
excruciating. These paroxysms recurred at irregular intervals,
Brodie’s Abscess goi
confining him to his room for many successive days, and being
attended with a considerable degree of constitutional disturbance.
Mr. P. described the disease as having existed more than twelve
years, and has having rendered his life miserable during the
whole of that period.
In the course of this time he had been under the care of various
surgeons, and various modes of treatment had been resorted to
without any permanent advantage. The remedies which I
prescribed for him were equally inefficacious. Finding himself
without any prospect of being relieved by other means, he made
up his mind to lose the limb by amputation; and Mr. Travers
having seen him with me in consultation, and having concurred
in the opinion, that this was the best course which could be pur-
sued, the operating was performed accordingly.*
(p. 241) On examining the amputated limb, it was found that
a quantity of new bone had been deposited on the surface of the
lower extremity of the tibia. This deposition of new bone was
manifestly the result of inflammation of the periosteum at some
former period. It was not less than one-third of an inch in
thickness, and when the tibia was divided longitudinally with a
saw, the line at which the new and old bone were united with
each other, was distinctly to be seen.
The whole of the lower extremity of the tibia was harder and
* It is right that I should state briefly the termination of the case; especially as the
circumstances attending it were probably connected with a peculiar condition of the
nervous system occasioned by the long continuance of the local disease. Unfortunately
I preserved no notes of this part of the case at the time, but I have no doubt that my
recollection is accurate as to the following particulars. The patient bore the operation
'with the utmost fortitude, but immediately afterwards he was observed to become ex-
ceedingly irritable, restless, and too much disposed to talk. Unfortunately in the evening
there was haemorrhage from the stump, which ceased, however, on the removal of the
dressings and coagulum. During the night he had no sleep; and on the following day he
'was restless, and incessantly talking, with a rapid pulse. These symptoms became
aggravated. There was no disposition to sleep, and the pulse became so rapid that it
could be scarcely reckoned. Until the third or fourth day the tongue remained clean and
moist. After this period it became dry, and somewhat brown, and there was constant
delirium. The pupils were widely dilated, and the sensibility of the retina was totallj-
destroyed, the glare of a candle not being perceptible even when held close to the e}e.
Death took place on the fifth day after the operation. No morbid appearances were ob-
served in tilt post-mortem examination.
Medical Classics
902
more compact than under ordinary circumstances, in consequence,
as it appeared, of some deposit of bone in the cancellous structure,
and in its centre, about one- third of an inch above the ankle,
(p. 242) there was a cavity of the size of an ordinary walnut,
filled with a dark-coloured pus. The bone immediately surround-
ing this cavity, was distinguished from that in the neighbourhood
by its being of a whiter colour, and of a still harder texture, and
the inner surface of the cavity presented an appearance of high
vascularity. The ankle-joint was free from disease.
It is evident that if the exact nature of the disease had been
understood, and the bone had been perforated with a trephine,
so as to allow the pus collected in its interior to escape, a cure
would probably have been effected, without the loss of the limb,
and with little or no danger to the patient’s life. Such, at least,
was the opinion which the circumstances of the case led me to
form at the time; and I bore them in my mind, in the expectation
that at some future period I might have the opportunity of
acting on the knowledge which they afforded me for the benefit
of another patient.
CASE 11
Mr. B., at that time twenty-three years of age, consulted me
in the beginning of February, 1826.
There was a considerable enlargement of the right tibia, be-
ginning immediately below the knee, and extending downwards
so as to occupy about one-third of the length of the bone.
(p. 243) Mr. B. complained of excessive pain, which disturbed
his rest at night, and some parts of the swelling were tender to
the touch. The knee itself was not swollen, and its motions were
perfect.
He said that the disease had begun more than ten years ago,
with a slight enlargement and pain in the upper extremity of the
tibia; and that these symptoms had gradually increased up to the
time of my being consulted. Various remedies had been em-
ployed, from which, however, he had derived little or no ad-
vantage.
Having inquired into the circumstances of the case, I was led
Brodie’s Abscess 903
to regard it as one of chronic periostitis; and I adopted the follow-
ing method of treatment. An incision was made longitudinally
on the anterior and inner part of the tibia, extending from the
knee four inches downwards, and penetrating through the
periosteum into the substance of the bone. The periosteum
was found considerably thickened, and the new bone, which had
been deposited beneath, was soft and vascular. The immediate
effect of the operation was to relieve the pain which the patient
suffered, so that he slept well on the next and every succeeding
night. After this I prescribed for him a strong decoction of
sarsaparilla. The wound gradually healed, and it was for some
time supposed that a perfect cure had been accomplished.
(p. 244) The enlargement of the upper extremity of the tibia,
however, never entirely subsided; and in August 1827 pain was
again experienced in it. At first the pain was trifling, but it
gradually increased, and when I was again consulted, in January
1828, Mr. B. was unable to walk about, and quite unfit for his
usual occupations. At this period the pain was constant, but
more severe at one time than at another, often preventing sleep
during several successive nights. The enlargement of the tibia
was as great as when I was first consulted; and the skin covering
it was tense and adhering more closely than is natural to the
surface of the bone.
Some remedies which I prescribed were productive of no benefit.
The patient’s sufferings were excruciating, and it was necessary
that he should, if possible, obtain immediate relief. The resem-
lance between the symptoms of this case and those of the case
already described, were too obvious to be overlooked. It ap-
peared highly probable that they depended on the same cause;
and I therefore proposed that the bone should be perforated with
a trephine, in the expectation that an abscess would be discovered
in its interior. To this the patient readily assented, and accord-
ingly the operation was performed in the beginning of March
1828.
My attention was directed to a spot about two inches below
the knee, to which the pain was particularly referred. This part
of the tibia was exposed by a crucial incision of the integuments.
Medical Classics
902
more compact than under ordinary circumstances, in consequence,
as it appeared, of some deposit of bone in the cancellous structure,
and in its centre, about one-third of an inch above the ankle,
(p. 24a) there was a cavity of the size of an ordinary walnut,
filled with a dark-coloured pus. The bone immediately surround-
ing this cavity, was distinguished from that in the neighbourhood
by its being of a whiter colour, and of a still harder texture, and
the inner surface of the cavity presented an appearance of high
vascularity. The ankle-joint was free from disease.
It is evident that if the exact nature of the disease had been
understood, and the bone had been perforated with a trephine,
so as to allow the pus collected in its interior to escape, a cure
would probably have been effected, without the loss of the limb,
and with little or no danger to the patient’s life. Such, at least,
was the opinion which the circumstances of the case led me to
form at the time; and I bore them in my mind, in the expectation
that at some future period I might have the opportunity of
acting on the knowledge which they afforded me for the benefit
of another patient.
CASE 11
Mr. B., at that time twenty-three years of age, consulted me
in the beginning of February, 1826.
There was a considerable enlargement of the right tibia, be-
ginning immediately below the knee, and extending downwards
so as to occupy about one-third of the length of the bone.
(p. 243) Mr. B. complained of excessive pain, which disturbed
his rest at night, and some parts of the swelling were tender to
the touch. The knee itself was not swollen, and its motions were
perfect.
He said that the disease had begun more than ten years ago,
with a slight enlargement and pain in the upper extremity of the
tibia; and that these symptoms had gradually increased up to the
time of my being consulted. Various remedies had been em-
ployed, from which, however, he had derived little or no ad-
vantage.
Having inquired into the circumstances of the case, I was led
Brodie’s Abscess 903
to regard it as one of chronic periostitis; and I adopted the follow-
ing method of treatment. An incision was made longitudinally
on the anterior and inner part of the tibia, extending from the
knee four inches downwards, and penetrating through the
periosteum into the substance of the bone. The periosteum
was found considerably thickened, and the new bone, which had
been deposited beneath, was soft and vascular. The immediate
effect of the operation was to relieve the pain which the patient
suffered, so that he slept well on the next and every succeeding
night. After this I prescribed for him a strong decoction of
sarsaparilla. The wound gradually healed, and it was for some
time supposed that a perfect cure had been accomplished.
(p. 244) The enlargement of the upper extremity of the tibia,
however, never entirely subsided; and in August 1827 pain was
again experienced in it. At first the pain was trifling, but it
gradually increased, and when I was again consulted, in January
1828, Mr. B. was unable to walk about, and quite unfit for his
usual occupations. At this period the pain was constant, but
more severe at one time than at another, often preventing sleep
during several successive nights. The enlargement of the tibia
was as great as when I was first consulted; and the skin covering
it was tense and adhering more closely than is natural to the
surface of the bone.
Some remedies which I prescribed were productive of no benefit.
The patient’s sufferings were excruciating, and it was necessary
that he should, if possible, obtain immediate relief. Theresem-
lance between the symptoms of this case and those of the case
already described, were too obvious to be overlooked. It ap-
peared highly probable that they depended on the same cause;
and I therefore proposed that the bone should be perforated with
a trephine, in the expectation that an abscess would be discovered
in its interior. To this the patient readily assented, and accord-
ingly the operation was performed in the beginning of March
1828.
My attention was directed to a spot about two inches below
the knee, to which the pain was particularly referred. This part
of the tibia was exposed by a crucial incision of the integuments.
Medical Classics
904
The periosteum now was not in the same state as at the time of
the former operation. It was scarcely thicker than natural, and
the bone beneath was hard and compact. A trephine of a middle
size was applied, and a circle of bone was removed extending in to
the cancellous structure, but no abscess was discovered. I then,
by means of a chisel, removed several other small portions of
bone at the bottom of the cavity made by the trephine. As I was
proceeding in this part of the operation the patient suddenly
experienced a sensation, which he afterwards described as being
similar to that which is produced by touching the cavity of a
carious tooth, but much more severe, and immediately some dark
coloured pus was seen to issue slowly from the part to which the
chisel had been last applied. This was absorbed by a sponge, so
that the quantity of pus which escaped was not accurately meas-
ured, but it appeared to amount in all to about two drams. From
this instant the peculiar pain belonging to the disease entirely
ceased, and it has never returned. The patient experienced a
good deal of pain, the consequence of the operation, for the first
twenty-four hours, after which there was little or no suffering.
The wound was dressed lightly to the bottom with lint. Nearly
six months elapsed before it was completely cicatrized: but in
about three months from the day of the operation, Mr. B. was
enabled to walk about and attend to his usual occupations. He
has continued well to the present time (January 7, 1832); and
the tibia is now reduced in (p. 246) size so as to be scarcely
larger than that of the other leg. No exfoliation of bone has ever
taken place.
CASE III
In the beginning of January 1830, Mr. S., thirty-four years of
age, consulted me on account of the following symptoms.
The lower extremity of the left tibia was considerably enlarged;
the skin covering it was tense, and adhered closely to the parts
below. The patient complained of a constant aching pain, which
he referred to the enlarged bone. Once in two or three weeks
there was an attack of pain more severe than usual, during which
his sufferings were excruciating, lasting several hours, and some-
Brodie’s Abscess
9°5
times one or two days, and rendering him altogether incapable of
following his usual occupations. The pain was described as
shooting and throbbing, worse during the night, and attended
with such exquisite tenderness of the parts in the neighbourhood
of the ankle that the slightest touch was intolerable.
Mr. S. said, that to the best of his recollection, the disease had
begun eighteen years ago, in the following manner. On going
to bed one evening he suddenly experienced a most acute pain
in the inner ankle. On the following morning he was unable to
put his foot to the ground, on account of the agony which every
attempt to do so occasioned. Leeches (p. 247) were applied
several times, and afterwards blisters, but the pain increased
notwithstanding. After some weeks an abscess presented itself
and broke. This was followed by some mitigation of the symp-
toms. Soon afterwards another abscess formed and broke in the
neighbourhood of the first. The two abscesses remained open
for a considerable time, and then healed rapidly. Mr. S. now
began to regain the use of the limb, and by degrees was able to
walk as usual.
During the following summer he had a recurrence of pain in the
inner ankle, without any further formation of abscess. For
eight or ten years afterwards there were occasional attacks of
pain, lasting one or two days at a time; the intervals between them
being of various duration, and in one instance, not less than nine
months. After this the attacks recurred more frequently, and
during the whole of the last two years the symptoms were nearly
as severe as at the time of my being consulted.
On examining the limb I was struck with the resemblance which
it bore to, that of the limb in each of the two preceding cases.
There was also a remarkable resemblance in the symptoms as
described by the patient, and I could not but suspect that they
depended on a similar cause. I requested that Mr. Travers,
who had attended one of the former cases with me, should be
consulted; and he agreed with me in the opinion that probably
an abscess existed in (p. 248) the centre of the tibia, and that it
would be advisable to perforate the bone with a trephine, with
the view of enabling the contents of the abscess to escape.
Medical Classics
906
Accordingly I performed the operation, with the assistance of
Mr. Travers, on the 31st of January. A crucial incision was made
through the skin, the angles of which were raised so as to expose
a part of the bone above the inner ankle, to which the pain was
especially referred. A small trephine was then applied, and a
circular portion of bone was removed extending into the cancel-
lous structure. Other portions of bone were removed with a
narrow chisel. At last about a dram of pus suddenly escaped
and rose into the opening made by the trephine and chisel. On
further examination a cavity was discovered from which the pus
had flowed, capable of - admitting the extremity of the finger.
The inner surface of this cavity was exquisitely tender; the
patient experiencing the most excruciating pain on the gentlest
introduction of the probe into it.
He passed a tolerable night, and suffered but little on the
following day. He continued to go on favourably until the 5th
of February, when a violent inflammation attacked the limb
immediately above the inner ankle. In spite of the application
of leeches, an abscess formed, which in the course of six or seven
days, presented itself immediately below the part at which the
trephine had been applied. An opening was made with a lancet,
and a considerable quantity (p. 249) of pus escaped, which had
apparently formed between the periosteum and bone, the latter
being felt exposed at the bottom of the abscess. During the
following month the inflammation excited by the operation con-
tinued, and several abscesses presented themselves in the neigh-
bourhood of the first. These however all healed favourably
without any exfoliation of bone taking place. The cavity made
by the trephine became filled up by granulation, and the wound
gradually cicatrized. From the time of the operation, the pe-
culiar pain from which the patient had previously suffered, was
entirely relieved: and it was not long before he was quite restored
to health, and able to walk and pursue his occupations without
interruption. I have seen him lately, nearly two years from the
time of the operation having been performed, and he continues
perfectly well.
THE END
Brodie’s Abscess
Lecture on Abscess of the Tibia
BY
SIR B. C. BRODIE, BART.
Delivered in the Theater of St. George’s Hospital, November ig, 1845. Published in
the London Medical Gazette, 36: 1399-1401, 1845
SHALL not make any introductory observations
to the course of lectures which I am about to
deliver, further than these — that on this, as on
former occasions, I do not pretend to give any
systematic course, but to select various subjects
in which I suppose you will feel interested, and
such especially as you will find to be of importance in surgical
practice. If I do not enter into the consideration of abstract
questions in physiology and pathology, it is not because I regard
these subjects as unimportant, but because I think it still more
important that in the few lectures which I shall deliver I should
contribute as much as I can towards making you useful to the
public and to yourselves as good practical surgeons.
The subject that I shall take for the present lecture, is one of
considerable interest, namely, the formation of abscess in the
interior of the tibia.
I need not tell you that bones are organized like soft parts;
that they have the same apparatus of arteries, veins, nerves, and
cellular tissue, and that they have superadded to these the un-
organized phosphate of lime. Having the same tissues as the soft
parts, they are liable to very much the same diseases, but then the
characters of these diseases, their symptoms, progress, and treat-
Medical Classics
908
ment, are much modified by the presence of the unyielding earthy
material which I have mentioned. Inflammation may take place
in bones, as it does elsewhere; it may go on to suppuration, and
abscess may form in their interior, as it does in the interior of
other organs. But there are these points of difference — an
abscess formed in a bone cannot very readily come to the surface,
so that it may remain pent up for an indefinite period: the soft
parts will stretch, bones will not, and the consequence is, that an
abscess situated in the latter is attended with much greater pain
than that which occurs in the former. The patient’s sufferings
are consequently more severe, and they are protracted for a very
much longer period.
I am not aware that I can explain to you better what I know
on the subject, than by relating some of the cases on which my
knowledge of it is founded.
In the year 1824 , 1 was consulted by a young man, 24 years of
age, under the following circumstances. There was a consider-
able enlargement of the lower end of the tibia, but the ankle-joint
admitted of every motion, and was apparently sound. The skin
was thin, tense, and closely adherent to the periosteum. There
was constant pain in the part, generally of a moderate character,
but every now and then it became excruciating, keeping the
patient awake at night, and confining him to the house for many
successive days. It made his life miserable, and his nervous
system irritable: one effect of which was that it spoiled his temper,
and thus produced another set of symptoms in addition to those
which were the direct consequences of the local malady. The
disease had been going on for 12 years. He had consulted a
number of surgeons respecting it, and had never derived benefit
from anything that was done. Instead of getting better, he
every year became so much worse. I tried some remedies with-
out any advantage, and at last recommended that he should lose
the limb. Mr. Travers saw him with me, and agreed in this
opinion. Amputation was performed, and the amputated tibia
is now on the table. You will see how much the lower end of it
is enlarged, and that the surface of it presents marks of great
vascularity. The bone in the preparation is divided longi-
Brodie’s Abscess 909
tudinally, and just above the articulating surface there is a cavity
as large as a small chestnut. This cavity was filled with dark
coloured pus. The inner surface of it is smooth. The bone
immediately surrounding it is harder than natural. The ex-
amination of the limb explained all the symptoms: there was an
abscess of the tibia, stretching the bone in which it was formed, or
rather, if I may use the expression, trying to stretch it, and thus
causing violent pain which the patient suffered. On observing
these appearances, I could not help saying, that if we had known
the real state of the disease, the limb might have been saved.
A trephine would have made an opening in the tibia, and have let
out the matter. It would have been merely applying the treat-
ment here that we adopt in the case of abscess elsewhere. You
open a painful abscess of the arm with a lancet; you cannot open
an abscess of the bone with a lancet but you may do so with a
trephine.
About two years after the occurrence of this case, I was con-
sulted by another patient, 23 years of age, who had an enlarge-
ment of the upper end of the tibia, extending to some distance
below the knee. He suffered a great deal of pain, the part was
very tender, and there were all the symptoms of chronic peri-
ostitis. I made an incision over the part, dividing everything
down to the (p. 1400) bone, and found the periosteum very
much thickened. There was a new deposit of bone under the
periosteum, softer than the bone of original formation. This
operation as in other cases of chronic periostitis, relieved the
tension and the pain, and the patient was supposed to be cured.
However, about a year afterwards, in August 1827, there was a
recurrence of the pain; the enlargement of the tibia, which had in
some degree subsided, returned, and it continued to increase. In
the enlarged tibia there was one spot a little below the knee, where
there was exceeding tenderness on pressure. I need not describe
the symptoms more particularly; it is sufficient to say, that they
bore a very close resemblance to those in the last case: the only
difference being that, as the disease had been of shorter duration,
the pain was less severe, and that the tibia was affected in the
upper instead of the lower extremity. I concluded that there
Medical Classics
910
must be an abscess in the centre of the bone, and applied the
trephine to the tender spot. I used the common trephine made
for injuries of the head, which, having a projecting rim or shoul-
der, would penetrate only to a certain depth. However, it
enabled me to remove a piece of bone of sufficient thickness to
expose the cancellous structure. Then with a chisel I removed
some more of the bone. Presently there was a flow of pus in such
quantit5 r as completely to fill the opening made by the trephine
and the chisel. It seemed as if the bone had been, to a certain
extent, kept on the stretch by the abscess, and that, as soon as an
opening was made into it, it contracted and forced up the matter.
The patient was well from that time; the wound healing very
favourably, and he has never had any return of the disease.
Sometime after this I was consulted by a gentleman who had
an enlargement of the lower end of the tibia. He suffered con-
stant pain, but every two or three weeks there was an exacer-
bation of it, and it was then very excruciating, almost intolerable.
These attacks sometimes lasted two or three days. This patient
when he came under my care was 34 years of age; he traced the
disease back for eighteen years, and stated that it began in the
following manner; on going to bed one evening, he felt a sudden
pain in or just above the ankle-joint; the next day there was a
swelling in this situation, he was laid up with inflammation, and
two abscesses burst in succession, but afterwards healed. He
continued well for some considerable time, and then he was again
seized with pain in the ankle. This pain was not constant, but
occurred at intervals. Sometimes there were several months
during which he was quite well. (These points are worthy of
notice with respect to the diagnosis, as I shall show you presently.)
After some years, however, the pain was never absent, and he
got into the state in which he was when he sought my advice.
On examining the ankle I found the tibia considerably enlarged.
The motion of the joint was perfect, but there was one tender
spot on the inside of the bone that seemed to indicate the seat of
an abscess. I applied a trephine here, and penetrated into a
cavity large enough to receive the end of the finger. There
gushed out a quantity of matter, perhaps a drachm, or more.
Brodie’s Abscess . 91 1
The inner surface of the cavity was exceedingly tender, so that
he could not bear the introduction of the finger, or even of a
probe. On the following day there was a good deal of inflamma-
tion in the neighbourhood of the part in which the operation was
performed; in the course of a few days an abscess formed, which
burst externally just below the ankle, and then the inflammation
subsided. The opening made by the trephine became filled up
with granulations, and the wound healed favourably. This took
place many years ago; I have seen the patient every now and
then since, and he has continued perfectly well.
I have had two cases of this kind under my care in this hospital.
One was a boy, who had a considerable enlargement of the lower
end of the tibia, attended with a great deal of pain. I trephined
the bone, and let out nearly half an ounce of matter. The other
was a man, whose case I will give you a little more in detail. His
name was Mowbray, and he was admitted in October 1838,
being then 24 years of age. He had an enlargement of the upper
end of the tibia, extending to the distance of 2J inches below the
knee. The circumference of the leg at this part was about an
inch more than that of the leg of the other side. The skin over
the enlarged bone was tense, and there was a blush of dark red-
ness on the inside. He said that six years ago there took place
some enlargement of the head of the tibia, attended with a dull
pain. Leeches were applied, and some other treatment was had
recourse to; I know not what. The pain continued for about six
months, it then subsided, and he became quite free from it, until
about three months before he came to the hospital, when it
returned, and the bone began to enlarge. The pain at the time
of his admission was so severe that he could not sleep at night.
It affected his health; he had lost flesh, and could take little or
no food. I concluded that there was probably an abscess in the
tibia, but as the disease had only been of short duration, I thought
it might be better to treat it as if it were merely chronic inflam-
mation in the first instance, having recourse to some other
remedies before I performed the operation. I prescribed, there-
fore, calomel and opium, sarsaparilla (p. 1401), and iodide of
potassium, one after the other. At last, there being no amend-
Medical Classics
912
ment, I applied the trephine at that spot where the bone ap-
peared more tender than elsewhere, and thus exposed an abscess,
which contained two or three drachms of pus. The relief was
immediate, and soon afterwards the patient left the hospital
cured.
I will mention another case. In the year 1841, a young lady
came to consult me on account of pain in the lower end of the
tibia. It began in the spring of 1835, when she had an attack of
what appeared to be inflammation of the bone. The pain was
at first confined to the lower end of the tibia, but afterwards she
had, in addition to it, other pains, apparently of a nervous
character, extending up the limb to the hip. She was of an
hysterical constitution, which might, perhaps, make the diagnosis
of the disease a little more difficult, the hysterical pain being
mixed up with the other. However, I found her having occa-
sional attacks of most severe pain in the lower end of the* tibia,
the bone being enlarged and tender to the touch; and, after a
most careful examination, I was satisfied that there must be an
abscess in the bone. Accordingly, I recommended the applica-
tion of the trephine. She could not then stay in town, and, either
because her surgical attendant in the country did not accord
with me in opinion, or because she would not submit to it, the
operation was not performed. She dragged on a very uncom-
fortable existence for four years more. In the interval she was
married, travelled abroad, had various opinions, tried different
remedies both here and elsewhere, but nothing afforded her any
relief. Last August she again came under my care: the tibia
was then very much enlarged; at times she was quite free from
pain, at other periods she had severe attacks of it, so that she
could not sleep at night. I was still of opinion that there was a
collection of matter within the tibia. Mr. Travers and Mr.
Key saw the patient with me, and it was agreed that I should
perforate the bone with the trephine. Accordingly I performed
the operation. The bone was excessively vascular, so that there
was a good deal of bleeding; and, towards the end of the operation,
a quantity of what appeared to be sero-purulent fluid gushed
out from beside the trephine, mixing with the blood. At the
Brodie’s Abscess
9 1 3
bottom of the bone removed by the instrument there was a
cavity that would just receive the end of the finger, and from
which the fluid had escaped. After this she had considerable
pain for some time, but evidently of an hysterical character.
She went into the country, and I have been just informed that
the wound has been for some time healed, and that she is free
from all her former symptoms. The piece of bone that was taken
away is upon the table; it is more hard and compact than it
ought to be just above the ankle, where, in the natural state,
there is a more cancellous structure. You will perceive on its
under surface, one corner of the cavity in which the sero-purulent
fluid was lodged.
Since I first published some observations on the subject, in the
year 1832, I have the satisfaction of knowing that similar cases
have been treated successfully in the same manner by other
surgeons. Mr. Liston has given me an account of two such cases,
which occurred in his practice, and I have in my possession the
written statement of a third one, in the hospital at Lincoln.
Now what are the circumstances that would lead you to sus-
pect the existence of abscess in the tibia? and supposing it to be
probable that such an abscess exists, how are you to proceed to
relieve it?
When the tibia is enlarged from a deposit of bone externally —
when there is excessive pain, such as may be supposed to depend
on extreme tension, the pain being aggravated at intervals, and
these symptoms continue and become aggravated, not yielding to
medicines or other treatment that may be had recourse to — then
you may reasonably suspect the existence of abscess in the centre
of the bone. You are not to suppose that there is no abscess
because the pain is not constant; on the contrary, it very often
comes on only at intervals, and in one of the cases which I have
related there was, as I then mentioned, an actual intermission of
seven or eight months. After the disease has existed a certain
number of years, indeed, the pain never entirely subsides, but
still it varies, and there are periods of abatement and of exacer-
bation. The combination of circumstances which I have de-
scribed will fully justify you in making an opening into the bone
Medical Classics
914
with a trephine. But how will it be if you are mistaken? This
will not often occur, but if it should, really the taking out of a
circle of bone can be of no consequence; no injury follows the
operation — it is unattended with danger. The operation is a
very simple one. You expose the surface of the bone, and make
a circular opening, with a trephine at that part where there seems
to be some tenderness and some pain on pressure. One principal
thing to be attended to is that you have a proper trephine. You
do not want so large a one as for the cranium, and it must be
some what differently constructed. Those which lie on the table
are made for the purpose. One is of very small diameter, but
generally it is quite sufficient. The common trephines are made
with a rim or shoulder, and if there be much enlargement of the
bone, they will not penetrate deep enough to reach (p. 1402) the
abscess. It is true that you may break away the bone after-
wards, by means of a chisel, but the operation may be more easily
performed with a trephine having no shoulder: which will at
once penetrate to the abscess, however deep it may be, and render
the chisel unnecessary. The after-treatment is as simple as
possible. There may be some pain for a day or two, and
especially, as in the case I last mentioned, if the patient be an
hysterical female, there may be hysterical pain afterwards; but
all that is required is to maintain the general health, and lay on
simple dressing; the bone soon granulates, the space is filled up
by a sort of fibrous substance, and the wound cicatrises.
But what would happen if you were not to perform the opera-
tion? The patient may continue in torture, as I have already
told you, for eighteen years, losing all the best part of his life;
or a worse event than that may take place. The preparation
which I show you is one of the oldest in the Museum. I attended
a patient who laboured under various diseases; there were tuber-
cles in the lungs, and vomicae; dead bone in the ribs and some
other local complaints which I forget. Besides all this, he had an
enlargement of the lower end of the tibia, attended with excessive
pain — pain, indeed, hardly to be borne, and which came on in
paroxysms lasting for many hours, and then in some degree
subsiding. By and by an abscess appeared externally, in the
Brodie’s Abscess
9 I 5
neighbourhood of the enlarged tibia, and then the pain ceased.
Under this complication of disease the patient sank, and died;
and on examining the body I found an abscess in the centre of the
tibia. One effect of the abscess had been to cause absorption of
the cartilage on the ankle-joint. It might have made its way
into the joint, but it took another course; and if you examine the
preparation, you will perceive on one side of the tibia a round
aperture, by which the matter escaped, and by which the external
and internal abscesses communicated with each other. It is
plain from this, that such an abscess cannot exist for many years
without the joint being endangered. In the year 1830, a young
gentleman, about thirteen years of age, came under my care.
He had just returned from Paris, where he had had an attack of
inflammation of the bone and periosteum of the tibia, for which
he had been under the care of the late Baron Dupuytren. The
inflammation terminated in necrosis. I removed some portions
of dead bone, others exfoliated without any operation, and for
three or four years pieces of bond continued to come away, none
of large size. Among the sinuses that were open, there was one
a little below the knee-joint; I could not ascertain whether bone
had come from it or not, but it closed and the patient appeared
quite well. In the year 1835 or 1836, however, I was consulted
by him again, on account of some pain in the upper end o t e
tibia. Whenever he walked, the knee-joint swelled becoming
full of fluid. I applied a splint, kept him quiet, and he seeme
quite to recover. I then left off the splint, and allowed im to
walk about as usual. The result was, that in the course o two or
three days the knee was again filled with synovia. On a ister
being applied, the fluid was again absorbed, then reappeare again
on exercise. Taking these circumstances into account, an
remembering that there had been pain for some time in the upper
end of the tibia, and formerly a sinus leading to the centre o t
bone, I thought it very probable that the knee-joint was on y
occasionally affected in consequence of some disease in . 1
neighbouring portion of the tibia. Mr. Keate an i r - *
saw the patient with me, and agreed in the opinion t at “
be prudent to perforate the head of the tibia wit a trep
Medical Classics
916
Finding, as well as I could, the most tender spot, I performed the
operation, and out gushed three or four drachms of matter.
There was no pain afterwards; the wound gradually contracted
and healed, and now, when the patient walked, there was no
swelling of the knee. The operation was performed in 1837,
and I have seen the patient occasionally ever since, and know
that he has had no return of the complaint. But is it possible to
doubt that, if the state of things I have described had gone on, the
knee-joint must have been destroyed? What would have hap-
pened if recourse had not been had to the operation? A case
occurred in this hospital, not exactly similar, but sufficiently so
to enable me to answer this question. A man of the name of
Hendrow was admitted, in February 1 837, with the upper end of
the tibia enlarged just below the knee-joint. There was an
opening leading down to the centre of the bone, and a probe passed
into it came in contact with a piece of bone that appeared to be
dead and loose, so that it was plain that a piece of bone in the
centre of the tibia had exfoliated and formed an abscess, which
had afterwards made its way externally. But that which renders
the case interesting as connected with the present inquiry is
this, that whenever the patient took exercise there was an accu-
mulation of fluid in the knee-joint, just as in the last case. The
swelling disappeared on the joint being kept quiet; and the motion
of the joint was perfect, or nearly so. It seemed plain that there
was a piece of dead bone in the centre of the tibia, which was
somehow or other doing mischief to the knee-joint. The course
to be pursued was evident. I (p. 1403) applied a trephine so as
to enlarge the opening through which the probe had passed; it
penetrated into a cavity in which there lay a piece of dead bone,
about the size of a horse-beam, which was at once removed. Un-
fortunately, the poor fellow, whose health had been in a bad
state previously, had an attack of erysipelas, and died. I took
particular care to examine the knee-joint, and I have the notes
of the dissection before me. The whole upper part of the tibia
was increased in size from a deposit of seabrous bone on the surface.
The cavity from which the dead bone had been extracted was of
the size of a large cherry, had a smooth internal surface, the bone
Brodie’s Abscess 917
around it being somewhat harder than natural. From this a
sinus extended up to the knee-joint, and opened into it just
at the anterior part of the spine of the tibia. There was no
suppuration in the joint. The cartilage covering the head of the
tibia in some places remained perfect, but only in narrow stripes;
in other parts it had degenerated into a substance something like
condensed membrane; in others the only vestige of it was a thin
membranous substance — so thin that you could see the bone
through it; and in others the bone of the tibia was completely
exposed, but not carious. The bone of the tibia was harder and
more compact than under ordinary circumstances. It was
curious that the condyles of the femur had suffered also, though
in a different manner. The bone, instead of being harder, was
softer than natural, so that you might cut it with a knife. The
cartilage adhered imperfectly to the bone; it could be peeled
off, and in some places it had begun to ulcerate. The softening
of the condyles of the tibia I have no doubt was the consequence,
and not the cause, of the disease; for you will observe that all
bones in a state of inaction lose a great part of their phosphate of
lime. After compound fracture, when the patient has been long
confined, the bone will actually become as soft as a scrofulous
bone, so that you may cut them with a knife.
The three last cases show that it is not safe to leave an abscess
in the lower end of the extremity of the tibia beyond a certain
time; that the joint is always in danger, and that the perforation
of the bone is the only remedy. Even if you were mistaken in
your diagnosis no harm can arise under certain circumstances
from taking away a piece of bone, where there is chronic inflam-
mation in it, even though there be no abscess. The following
very remarkable case will illustrate this last observation. A
young gentleman who lived at Brixton, was brought to me by
Mr. Crowdy, a practitioner of that place, with violent pain in the
middle of one arm, the bone itself being enlarged in that part to
which the pain was referred. Some remedies were tried, which
I need not enumerate, without any benefit. The pain continued,
and I began to suspect that there might be an abscess in the
centre of the bone. Under this impression I proposed cutting
Medical Classics
918
down upon it, and making an opening with the trephine, so that
I might remove the matter, if there were any there. The opera-
tion was performed; the trephine penetrated to the centre of the
bone, but no matter escaped. I persevered, but still there was
no matter, and at last the instrument penetrated completely
from one side of the bone to the other. The bone was very hard
and compact, and it was as much as the trephine would do to run
it through. I thought that I had made a blunder, and that there
being no abscess the operation would not be attended with any
benefit. The next morning the patient had an attack of pain
almost as severe as before the operation, but it did not last long,
and he never had any pain afterwards. The wound healed, the
relief was completely, and I heard of the patient not long ago as
having continued well. I presume that this was a case of chronic
inflammation of the humerus, and that taking out the piece of
bone from the centre, probably partly by relieving the tension,
and partly by a discharge of matter from the bone, unloading the
vessels, accounted for the relief which the patient obtained from
the operation.
THE END
Brodie’s Disease of Joints
Further Observations on the Diseases Which Affect the
Synovial Membranes of Joints
BY
B. C. BRODIE, ESQ., F.R.S.
Assistant Surgeon to St. George’s Hospital
Read July 19, 1814.
Published in Medico-Chirurgical Transactions, London, 5:
a 39“®54» i8i 4
I
‘URING the last session I had the honour of pre-
senting to the Society an account of several
cases, which appeared to throw light on the
pathological history and classification of the
diseases of the human joints. In the present
paper, I propose to communicate some brief
practical observations on the symptoms, by which those diseases,
which affect the synovial membranes, are to be distinguished,
and on the treatment, which should be adopted for their relief.
On the latter subject indeed, what I have to offer may seem to
have little or no claim to the merit of novelty. The effects of
the various methods of treatment (p. 240) now employed by
physicians and surgeons are for the most part of accidental
discovery. The improvement of scientific pathology seldom
leads to the invention of new remedies; but it enables us to under-
stand better the application of those, which are already in use;
to know the particular cases to which particular remedies are
suited, and to distinguish the curable diseases, from those, in
which a cure cannot be effected.
919
Medical Classics
920
II. On the causes and symptoms of inflammation of the Synovial
Membrane
Inflammation of the synovial membranes may occur as a symp-
tom of a constitutional disease, where the system is affected by
rheumatism; where mercury has been exhibited improperly, or in
large quantities, or where there is general debility from any other
cause. But in these cases, the inflammation is seldom severe;
it occasions an effusion of fluid into the joint, but rarely termi-
nates in the extravasation of coagulable lymph, or thickening of
the inflamed membrane. Sometimes it leaves one joint to attack
another, or it suddenly subsides without another joint becoming
affected.
At other times the inflammation occurs as a local affection
produced by a sprain, the application (p. 241) of cold, or arising
from no evident cause. It is here for the most part more severe,
and of longer duration: it leaves the joint with its functions
more or less impaired, and occasionally terminates in its total
destruction. In itself it is a serious disease, but it is often con-
founded, under the general name of white swelling, with other
diseases, still more serious. In some cases, it assumes the form
of an acute, but in the greater number of instances, it has that of
a chronic inflammation.*
In the former, there is pain and tenderness of the joint, and
usually redness of the skin. The pain is severe; not referred to a
particular spot, but to the whole joint. When the pain has
existed for some time, swelling takes place. The period at which
the swelling shews itself, varies from a few hours, to two or three
days, from the commencement of an attack. The patient usually
keeps the limb a little bent, and every attempt to bend or extend
it further aggravates the pain. (p. 242) With these symptoms,
* It is to be observed, that the boundaries of acute and chronic Inflammation in these,
and in other cases, are not well defined. These terms accurately enough express the two
extremes, but there are intermediate degrees of inflammation of which it is difficult to
decide, whether they should be considered as being of the acute or chronic kind. Lan-
guage can not supply names for all the varieties of morbid action which occur, but the
surgeon will learn to distinguish them, and the corresponding varieties of treatment, and
it is this nicer discrimination which forms a principal difference between the experi-
enced and inexperienced practitioner.
Brodie’s Disease of Joints 921
there is inflammatory fever. In a few days the disease either
subsides altogether, or assumes the chronic form: more frequently
it has this form from the beginning.
Where there is chronic inflammation of the synovial membrane,
the pain and tenderness are less, so that the patient is able to walk
about, and often without experiencing any severe distress. There
is no unusual redness of the skin, and little or no fever. The
swelling begins soon after the commencement of the attack, but
it increases less rapidly than where the inflammation is acute.
These symptoms vary in degree at different periods, and gen-
erally are aggravated by exposure to cold or any unusual exertion.
In the first instance, the swelling of the joint arises entirely
from a preternatural quantity of synovia being collected in its
cavity. In the superficial joints, the fluid may be distinctly felt
to undulate, when pressure is made alternately by the two hands
placed one on each side. When the inflammation has existed for
some time, the fluid is less perceptible than before, in consequence
of the synovial membrane having become thickened, or from the
effusion of lymph on its inner or outer surface; and in many
cases, when the disease has been of long standing, although the
joint is much swollen, and the symptoms of inflammation still
exist, the fluid in its cavity is scarcely to be felt. As the swelling
consists more of solid substance, so the (p. 243) natural mobility
of the joint is in a greater degree impaired.
The form of the swelling deserves notice. It is not that of the
articulating ends of the bones, and therefore it differs from the
natural form of the joint. The swelling arises principally from
the distended state of the synovial membrane, and hence its
figure depends in great measure on the situation of the ligaments
and tendons, which resist it in certain directions and allow it to
take place in others. Thus, when the knee is affected, the swell-
ing is principally observable on the anterior and lower part of
the thigh, under the extensor muscles, where there is only a
yielding cellular structure between those muscles and the bone.
It is also often considerable in the spaces between the ligament of
the patella and the lateral ligaments, the fluid collected in the
cavity causing the fatty substance of the joint to protrude in this
922 Medical Classics
situation, where the resistance of the external parts is less than
elsewhere. In the elbow the swelling is principally observable
on the posterior part of the arm, above the olecranon and under
the extensor muscles of the fore-arm; and in the ankle it shews
itself on each side, in the space between the lateral ligaments and
the tendons, which are situated on the anterior part. In like
manner in other joints, the figure of the swelling, whether it arises
from fluid, along, or joined with solid substance, depends in great
measure on the ligaments (p. 244) and tendons in the neighbour-
hood, and on the degree of resistance which they afford, and these
circumstances, though apparently trifling, deserve our attention,
as they enable us more readily to form our diagnosis.
In the hip and shoulder the disease occurs less frequently than
in the superficial joints. The effused fluid can not here be felt
to undulate, but the swelling is perceptible through the muscles
which cover it. When the hip is affected the pain is usually
confined to the hip itself; sometimes it is referred to the knee
also, as in cases where the cartilages of the hip are ulcerated.
The following circumstances enable us to distinguish the two
diseases from each other. In the former the pain is more severe
in the first instance than afterwards; and there is welling of the
nates. In the latter the pain is trifling at first; becomes grad-
ually worse, till it is at last exceedingly severe, and the nates
are wasted and flattened instead of being swollen.
After the inflammation of the synovial membrane has sub-
sided, the fluid is absorbed, and in some instances the joint regains
its natural figure and mobility; but in the majority of cases
stiffness and swelling remain. In the superficial joints the
swelling has sometimes the form of the articulating ends of the
bones, that is, the natural form of the joint, and we may suppose
it in this case to arise (p. 245) from the thickened state of the
synovial membrane. At other times it has the same peculiar
form, which it possessed while the inflammation existed, and
while fluid was contained in the joint, and we may suppose that
it depends principally on the inner surface of the synovial mem-
brane having a thick lining of coagulable lymph.
The chronic inflammation of the synovial membrane often
Brodie’s Disease of Joints 923
continues for many months, and after having subsided is very
liable to recur from slight causes. Thus a person has this disease
in his knee; the inflammation is cured, but tumor and stiffness
remain. Whenever he is exposed to cold, or exercises the limb in
an unusual degree, and often without any evident reason, the
pain returns and the swelling is augmented. Such cases are of
frequent occurrence, and they form a large proportion of those
which are known by the name of white swelling.
Long continued and neglected inflammation of the synovial
membrane occasionally terminates in the formation of an abscess
in the cavity of the joint, in ulceration of the cartilages, and in
complete destruction of the articulating surfaces. In this last
stage, if we wish to know whether the inflammation of the syno-
vial membrane, or the ulceration of the cartilage, has been the
primary disease, we must form our judgment, not from the present
symptoms, but from the previous history (p. 246) of the case.
It is indeed often difficult to procure a history, on the accuracy
of which we can rely, particularly in hospital practice; but this is
of less importance, as whatever the disease may have been in its
origin, where it has proceeded so far as has been described, there
is no difference with respect to the treatment; and in general, no
remedy can be employed with any prospect of advantage, except
the removal of the limb by amputation.
III. On the 'Treatment of the Inflammation of the Synovial
Membrane
In the acute form of the disease, leeches may be applied to the
part; and in most instances it will be right to take blood from the
arm. Warm fomentations produce better effects than cold
lotions. Attentions should be paid to the state of the bowels, and
Dover’s powder, or some other diaphoretic medicine, ma) be
exhibited. Under this treatment the acute inflammation in
general speedily subsides.
The chronic inflammation is relieved more slowly. In t e
first instance, the joint should be kept in a state of perfect rest.
Blood should be taken from the part by means of leeches or
cupping, and this may be followed by the application of a blister,
Medical Classics
924
(p. 247) large enough to include the greater part of the circum-
ference of the joint. Under this treatment the pain is relieved,
and in a few days the swelling, as far as it depends on the fluid
collected in the cavity of the joint, is much diminished. Even
where the tumor is solid, arising from the effusion of coagulable
lymph, it will in a great degree subside, and sometimes be en-
tirely dispersed, provided the lymph has not yet become organ-
ized. A single blister often produces marked good effects, but it is
generally necessary to repeat both the blister and the blood-
letting several times. The repeated application of blisters is
more efficacious than a single blister kept open by the savine
cerate, or by other means, for a considerable time. When the
inflammation is in a great measure subdued, a moderate degree of
exercise of the joint is rather beneficial than otherwise. Lini-
ments, which irritate the skin, may be rubbed on twice or three
times in the day. The following liniment is more stimulating
than those in common use, and has appeared to me in most in-
stances to have been productive of much better effects with
respect to the disease.
Olei Olivae oz. iss.
Acidi Sulphurici oz. fs. M. fiat linimentum.
It may be used of this strength for the class of persons, who
apply at an hospital for relief; but for persons of a higher class in
society, in whom (p. 248) the cuticle is thinner, and the cutis more
easily irritated, the proportion of the olive oil should be greater.
The effect of this liniment is to excite some degree of inflammation
of the skin; the cuticle becomes of a brown colour, and separates
in thick, broad scales, and the inflammation of the internal parts
is relieved, probably on the same principle as by a blister. The
friction used in applying the liniment appears to be of service
after the inflammation is nearly subdued, but if friction be em-
ployed in the first instance the disease is aggravated.
No other remedies seem to be productive of much benefit.
Issues and setons, which are useful in cases of ulceration of the
cartilage, are of no service whatever in this disease.
Plasters of gum ammoniac, and others of a similar nature, are
Brodie’s Disease of Joints 925
of little efficacy, while inflammation still exists; but afterwards
they are of use in guarding the joint from the influence of the
external cold, and preventing a relapse.
The swelling and stiffness that remain after the inflammation
has subsided, if moderate in degree, may be relieved by the free
exercise of the limb, and by friction. The mercurial ointment
with camphor may be rubbed on the joint; or friction (p. 249)
may be made by the hand with starch or other fine powder.
The friction however should be employed with caution, as, when
used too freely, it sometimes occasions a return of the inflam-
mation. Whenever there is the slightest indication of this being
the case, the friction should be omitted for a time, and leeches
should be applied, and if the friction be resumed it should be
employed in a less degree, and less frequently than before.
When the swelling and stiffness in consequence of the inflam-
mation are very considerable, I have seldom known much, and
I have never known entire relief produced by friction or by any
other means. Here too the patient is more liable to a return of
the inflammation, and hence friction must be employed with still
greater caution than in other cases.
On the whole I have not found so much good produced by
friction, as from what I had heard of its effects, I had been led to
expect; and I have known it, when used too freely, or too early
in the disease, to delay rather than to expedite the cure. Friction
appears to be more efficacious where the stiffness of a joint
depends on a contracted state of the muscles or tendons of the
limb, and on these being glued to each other and to the surround-
ing parts, than where it is the consequence of disease in the joint
itself.
(p. 250) I have in several instances tried the effect of pumping
hot water on a stiff joint, as recommended by Le Dran, and as
now practised at some watering-places. The blow of a column
of water falling from a height of several feet produces considerable
friction, with which are combined the relaxing powers of heat and
moisture. This practice is certainly productive of benefit, but
the observations just made apply to this as well as to the other
modes of producing friction.
926 Medical Classics
IV. On the Symptoms -produced in those Cases, in which the Synovial
Membrane has undergorie a morbid Change of Structure
In my former communication respecting the diseases of the
joints, I gave an account of several cases, in which the synovial
membrane had undergone a peculiar morbid alteration of struc-
ture. The observations which I then made have been -fully
confirmed by many similar cases which have since come under
my notice. This disease generally takes place in young persons
under, or not much above, the age of puberty. I do not recollect
more than one instance of it having occurred after the middle
period of life. In general it can be traced to no evident cause;
but occasionally it takes place as a consequence of repeated
attacks of inflammation. In this respect it resembles other
diseases of the same order. Inflammation of the lungs may
produce tubercles, and inflammation of the breast may occasion
the growth of a schirrous tumor. Where I have had an oppor-
tunity of examining the morbid appearances after amputation,
I have always found the whole, or nearly the whole of the synovial
membrane affected by the disease; but it is probable, that if the
examinations were made at an earlier period, we should always
find the morbid change originating in some one point. A patient
was admitted into St. George’s Hospital in whom this disease
was beginning on the inside of the knee: from thence (in the course
of three months) it gradually extended itself in every direction
over the whole circumference of the joint. In a girl, who laboured
under this affection of the knee, but who died in the hospital of
another complaint, I found one-half of the synovial membrane in
a state of disease, and the other half retaining its natural struc-
ture and appearance.
In the origin of this disease there is a slight degree of stiffness
and tumefaction, without pain, and producing only the most
trifling inconvenience. These symptoms gradually increase; at
last the joint scarcely admits of the smallest motion, the stiffness
being greater than where it is the consequence of simple inflam-
mation. The form of the swelling bears some resemblance to
that in cases of inflammation of the synovial membrane (p. 25a),
but it is less regular. The swelling is soft and elastic, and gives
Brodie’s Disease of Joints 927
to the hand a sensation as if it contained fluid. If only one hand
be employed in' making the examination, the deception may be
complete, and the most experienced surgeon may be led to sup-
pose that there is fluid in the joint, when there is none; but if
both hands be employed, one on each side, the absence of fluid is
distinguished by the want of fluctuation.
The patient experiences little or no pain until abscesses being
to form, and the cartilages ulcerate; and even then the pain is
not severe, as where the ulceration of the cartilages occurs as a
primary disease, and the abscesses heal more readily, and dis-
charge a smaller quantity of pus than in cases of this last descrip-
tion. At this period the patient becomes affected with hectic
fever; loses his flesh, and gradually sinks, unless the limb be
removed by an operation.
The progress of this disease varies in different cases. In
general one or two years elapse before it reaches its most ad-
vanced stage; but sometimes the period is much longer; and
occasionally it becomes indolent, so that it remains during many
months without any sensible alteration. In like manner tuber-
cles of the lungs, or schirrus of the breast in some instances
remain in an inactive state for several months, or even for some
years.
(p. 253) The diagnosis of this disease is seldom difficult.
The gradual progress of the enlargement and stiffness of the
joint without pain; and the soft elastic swelling without fluctua-
tion, in most instances enable us to distinguish it, not only from
inflammation of the synovial membrane, but also from the other
morbid affections to which the joints are liable.
V. On the Treatment of Cases, in which the Synovial Membrane has
undergone a morbid Alteration of Structure
Where there is welling and hardness following inflammation,
the substance which has been effused may be absorbed, an t e
swelling and hardness may disappear, but I know of no instance
in which an organ having completely lost its natural structure
is capable of having that structure restored. Physicians an
surgeons have been employed during successive ages in en ea% our
Medical Classics
928
ing to discover a cure for tubercles of the lungs, and cancer of
the breast, and the result of their labours is only to prove that
these diseases are incurable. Analogy therefore would not lead
us to be sanguine as to the discovery of a remedy for this disease
of the synovial membrane, and experience shews that it is equally
incurable with other maladies of the same order. By means of
rest and cold lotions the progress of the disease may (p. 254)
be somewhat checked, as suppuration of tuberculated lungs may
be retarded by occasional bleeding, and a milder climate; but
ultimately the ulceration of the cartilages, the formation of
abscess in the cavity of the joint, and the consequent disturbance
of the general health, render the amputation of the limb necessary
in order to preserve the patient’s life. At this period therefore
the surgeon is called upon to recommend, and to urge an opera-
tion; but at an earlier period it is a matter of choice with the
patient, whether he will live with the incumbrance of an useless
limb, till the advanced stage of the disease renders its removal
indispensable, or whether he will submit to the loss of it before
the absolute necessity for losing it exists.
Brodie’s Pile
Lectures on Diseases of the Rectum
BY
SIR B. C. BRODIE, BART.
Lecture III. Preternatural Contraction of the
Sphincter Ani
Delivered at St. George’s Hospital. Published in The London Medical Gazette, 16:
26-31, 1835
LIE orifice of the anus, as you know, is closed
by the sphincter muscle. The ordinary condi-
tion of this muscle is that of being contracted,
and thus it prevents the involuntary discharge
of feces from the rectum. In the expulsion of
the alvine evacuations, the effort of the ab-
dominal muscles and diaphragm is always attended with a relaxa-
tion of the sphincter muscle, in consequence of which the contents
of the bowel are allowed readily to escape. If this consent and
sympathy between these different muscles did not exist the
whole of them being in a state of contraction at the same time
the feces would be expelled with very great difficulty and distress
to the patient, or not at all. Now it happens that this state of
things sometimes actually exists, and the result is precisely what
I have mentioned. The contraction of the sphincter at first ap-
pears to be merely spasmodic, without any other change of its
condition; but you know, that in proportion as muscles are
called into greater action, so they become increased in bulk; and,
in conformity with this general rule, when spasmodic contraction
of the sphincter muscle has existed for a long time, the muse e
Medical Classics
930
becomes considerably larger than it was in its natural state
before the disease existed.
This disease is not of uncommon occurrence. It is met with
chiefly in women, especially those who are disposed to hysteria.
It is, however, met with in other women, and sometimes in the
male sex.
The patient, under these circumstances, is forced to strain
very much in passing her evacuations; and this is especially the
case when the feces are hard, or even solid. There is pain not
only when the feces are being passed, but for a very considerable
length of time afterwards; and in some cases the pain will remain
from the period of one alvine evacuation to that of another; so
that it is constant, or nearly so. It is remarkable what misery
some persons suffer under the circumstances which I have just
described.
In connection with spasmodic contraction of the sphincter
muscle, you will frequently find a small ulcer of the mucous
membrane of the rectum. This ulcer is always in a particular
spot, at the posterior part, opposite to the point of the os coccygis.
I imagine that it arises from the mucous membrane there being
torn by the pressure of the hard feces, at the time that the evacua-
tion is labouring, as it were, to get through the contracted orifice
of the anus. Such an ulcer as I have just described adds very
much to the patient’s sufferings; it is always excessively sensitive;
the least pressure of the finger upon it occasions the greatest pain,
and the pressure of solid feces produces the same effect.
An ulcer of this kind is met with in some cases independently of
disease of the sphincter muscle; but to that I shall advert here-
after.
treatment . — When the patient does not suffer excessively from
this disease, you may sometimes relieve her in the following
manner: Give her purgative medicine, so that she may never have
hard or figured evacuations, and let an opiate suppository be
introduced at night. I have formerly used a suppository with
extract of belladonna, with manifest advantage; but I owe that
I am not in the habit of frequently employing this remedy.
Even (p. 27) used in the form of a suppository, the belladonna
sometimes produces very serious symptoms, by its influence on
Brodie’s Pile 931
the brain. In addition to what I have mentioned, the patient
may introduce a bougie into the anus, to dilate the orifice of the
bowel, each time before she goes to the water-closet.
These remedies, however, are of no avail in bad cases of this
disease; and then it is absolutely necessary to resort to some
more certain means of cure. It may always be relieved by a
simple operation — the division of the sphincter ani muscle.
You introduce a straight probe-pointed bistoury into the anus, and
cut through the fibres of the muscle, taking care not to penetrate
beyond them. The fibres are of considerable thickness, and you
cannot cut them through at one incision, nor should you attempt
it; the knife must be drawn across the muscle two or three times
before the operation is completed. It is generally sufficient if
you divide the muscle on one side. It is better to divide it
laterally than either in the posterior or anterior direction. The
wound does not readily heal if the division be made towards
either the perineum or the os coccygis; nay, more than that, if in
the female you divide the muscle towards the perineum, and con-
sequently towards the vagina, you make the patient miserable
for life, for there is incontinence of fseces ever afterwards; whereas,
if you divide it in any other direction, this inconvenience is alto-
gether avoided after the wound is healed.
The operation of dividing the sphincter muscle is not very
painful, except in those cases where the disease is complicated
with ulcer at the back part of the rectum; neither is there ever
any hsemorrhage of consequence, as the pressure of the finger, or
a plug of lint, will always command it. The relief is immediate;
and the very next time that the patient has an evacuation,
there is an end of all the pain and difficulty which she suffered
before. It is better, however, that she should not have an
evacuation immediately after the operation, and therefore I
generally give her an active purgative on the preceding day, and
some opium afterwards to keep the bowels constipated. After
two or three days castor oil may be exhibited, and the bowels
opened. The wound requires very simple treatment; a little
dressing of lint may be applied to it till it is cicatrized; and
cicatrization is generally completed in about three weeks.
No inconvenience whatever follows the division of the sphincter
Medical Classics
932
muscle, except it be made, as I have mentioned, in the female,
in the direction forwards. The patient retains her feces as well
as ever, and yet the difficulty of voiding them is relieved. All the
symptoms, so far as I have seen, are permanently removed. I
have performed this operation of dividing the sphincter muscle for
this disease, and in other cases, a great many times; and I have
been accustomed to say that it is an operation free from danger;
but, after all, there is no operation in surgery, not even the
slightest, of which we can assert this as a general proposition,
or as one to which there are absolutely no exceptions. The
utmost that we can venture to say is, that the probability of any
bad result is so small, that we ought not to calculate on it; and
that if we were to calculate on such chances in the common
affairs of life, we should do nothing. I have known two instances
of persons dying after the extraction of a tooth; I have known
others die in consequence of being bled in the arm, or of erysipleas
occurring after being cupped. I have known the bite of a leech,
and the sting of a wasp, and the prick of a pin, to prove fatal;
and I have lately had the misfortune of losing a patient after the
division of the sphincter ani muscle. The case ' occurred in a
lady of a peculiarly susceptible nervous system. Immediately
after the operation she fell into what might be called a state of
hysterical syncope, from which she did not recover until after
the lapse of three or four hours. She died at the end of a week,
with inflammation of the pleurae and peritonaeum, which had
caused a very large effusion of turbid serum into the cavities of
the chest, and a smaller effusion into that of the abdomen also.
There was no inflammation of the rectum, nor of the cellular
membrane or other textures in immediate connexion with it;
and it was evident that the pleuritic and peritonseal inflammation
had not extended from the part on which the operation had been
performed, but that it had been the result of the impression
made on the system generally. I cannot so well compare the
case to any thing, as to one of puerperal fever.
ULCER ON THE INSIDE OF THE RECTUM
The ulcer which occurs in connexion with a contracted sphincter
muscle, in some instances exists independently of it. You may
Brodie’s Pile
933
discover it on the posterior part of the rectum, opposite to the
point of the os coccygis; and, as I have already stated, it occurs,
for the most part, in persons who have costive bowels and hard
stools, the mucous membrane being under these circumstances
lacerated by the pressure of hard evacuations. When once pro-
duced, the ulcer is very difficult to heal, and very frequently it
goes on spreading till it becomes of considerable size. It is a
superficial ulcer, of exquisite sensibility, and (p. 28) great pain
is always produced by the passage of the faeces over it, lasting for
a considerable time after each evacuation. In some instances,
considerable haemorrhage takes place from an ulcer of this kind.
‘ Treatment . — The ulcer is always cured by a division of the
sphincter muscle. This, however, is not always necessary, unless
the muscle be actually contracted. Mr. Copeland has observed,
that when there is a simple ulcer, the mere setting of the mucous
membrane at liberty, by dividing it longitudinally, so as to in-
clude the ulcer in the incision, is sufficient to effect a cure. I
have known this to succeed in several instances, and I believe
that it is Mr. Copeland’s ordinary practice. However, a cure
may be obtained, in many instances, without an operation of
any kind, by means of the conf. piperis compos, or Ward’s paste,
given internally (the bowels being at the same time kept gently
open by the use of lenitive electuary and sulphur, or some other
simple aperient). Ward’s, paste may be applied locally also.
I had a case, not long since, in which the patient was unwilling to
submit to the division of the mucous membrane, and where she
got well under the use of suppositories of Ward’s paste and soap.
A piece of this, blended with soap, was introduced into the rectum
twice a-day, gentle aperients being exhibited at the same time,
so as to prevent her having hard evacuations.
STRICTURE OF THE RECTUM
Under the appellation “stricture of the rectum, various dis-
eases have been confounded with each other some malignant,
and some not malignant; but I am going to speak now of that
stricture or contraction of the gut which does not partake o a
malignant character. Malignant diseases of this organ will be
considered in another lecture.
Medical Classics
934
Here is a specimen [presenting it] of stricture of the rectum.
On dissecting a case of simple stricture of the rectum, I have
found the mucous membrane thickened, of a harder structure than
natural, and the muscular tunic thickened also. The stricture
sometimes occupies the whole length of the gut, for some wa^ up
above the anus — perhaps three or four inches, as in the specimen
just shewn you; at other times it is only of short extent. Fre-
quently the gut is of its natural diameter close to the anus, and
about an inch and a half or two inches above it there is a circular
contraction, and then above that the gut is of its natural diam-
eter again. Although the contraction may occupy only a small
portion of the length of the rectum, yet the disease of the tunics
is generally more extensive. Thus, if there be a contraction of
the gut two inches above the anus, you find the mucous membrane
between the stricture and the anus thickened, and in an un-
healthy state; and on passing the finger through the stricture
into that portion of the gut above it, you will find the mucous
membrane in this situation in an unhealthy state also.
The disease occurs in either sex: in adult persons more than in
children. It comes on gradually. The patient finds a little
difficulty in passing the evacuations; then the difficulty becomes
greater; he is forced to strain when at the water-closet, especially
if the feces be hard; and at the same time the feces are observed
to be of a very small diameter. The constant straining against
the stricture causes, the diseased part to become inflamed, and
then the evacuation is attended with a great deal of pain, there
being also a discharge of mucus constantly dribbling from the
anus, and staining the patient’s linen of a brown colour. As the
disease advances, some parts of the mucous membrane ulcerate.
This causes the pain to be much aggravated, there being then a
discharge not only of mucus, but of blood and pus from the anus.
If the disease proceeds still farther, inflammation takes place in
the cellular membrane around the gut; putrid abscesses form,
which burst in various situations at every side of the anus, into
the urethra in men, and occasionally in women into the vagina.
These abscesses are probably formed in the following manner: —
ulceration takes place of the mucous membrane, and of the muscu-
Brodie’s Pile
935
lar tunic of the gut, in consequence of which a very small com-
munication is formed between the cavity of the rectum and the
cellular membrane in the neighbourhood; then some small portion
of the contents of the bowel escapes into the cellular membrane,
inducing inflammation and suppuration, the admixture of a
little fseculent matter causing the contents of the abscess to be
putrid. In some instances the patient dies with symptoms of
strangulated hernia — that is, a piece of hard fasces is lodged above
the stricture, and cannot pass through it; thus there is a me-
chanical obstruction to the passage of the faeces; the belly becomes
tympanitic, the tongue dry; there is sickness, vomiting, and the
other symptoms indicating strangulation. He may have one of
these attacks, and by means of injections, and the use of a bougie,
may recover; he may have a second, and recover from that; and
then he may have a third, which may prove fatal. In the most
advanced stage of this disease, independently of these attacks,
the patient suffers much (p. 29) in his general health, loses flesh,
perspires at night, his digestion is deranged, he is emaciated and
hectic, and thus gradually becomes exhausted.
The progress of the disease which I have thus described in a
few words, is, however, lingering and tedious. The patient
may die, even where no remedies are employed, after ten or
twelve years of inconvenience first, and of suffering afterwards.
In some cases, under a judicious treatment, although the disease
cannot be cured, it may be much mitigated, and may never prove
fatal.
’Treatment . — When you are called to a patient with stricture
of the rectum, you should first make an examination with the
finger, so as to ascertain exactly where the stricture is situated,
how high up it extends, and how much of the gut is included in
it. If the stricture be not in a very irritable and tender state,
the patient may at once derive benefit from mechanical dilatation
by the use of a bougie. You will ascertain the diameter of the
stricture with the finger as nearly as you can do so, and introduce
a bougie, of proper size, through its orifice. The bougie must be
allowed to remain in the stricture five or ten minutes, or in some
cases for a longer time; and the operation must be repeated e\ erj
Medical Classics
93 6
day, or every other day, according to circumstances. In this
manner you will gradually be enabled, in the early stage of the
disease — I will not say to restore the gut to its natural diameter —
but to dilate the stricture so much that the evacuations may be
readily discharged, and that the patient may suffer but little
inconvenience from it. I saw not long since a lady respecting
whom I had been consulted about three or four years previously.
At that time the stricture was so great, that I could introduce
only a small urethra bougie. I directed her to commence a
course of bougies, which her medical attendant introduced for her.
They were very gradually increased in size; and when I last saw
her the stricture would admit one of very large diameter; and
she experienced no more than the slightest inconvenience from
the complaint. Here, as in cases of stricture of the urethra, the
use of the bougie must be continued. If it be neglected the stric-
ture will return, and be worse than ever.
In some cases of this disease you may facilitate the process of
cure in the following manner. In the cases to which I allude,
the stricture is situated about two inches above the anus, and
occupies only a small portion of the length of the gut. It forms
a circular band, embracing the finger, as narrow as a cord. A
stricture of this kind may be divided in two or three parts of its
diameter, before you begin the use of the bougie, in the following
manner: — Introduce a bistouri cache , and let the screw be so ad-
justed that the blade may be opened about the sixth of an inch,
but certainly not more than a quarter of an inch. The bistouri
must be introduced with the blade shut; then press on the handle,
open the blade, and, drawing it out, you nick the stricture first
in one part of its diameter, then in another, and then in a third.
This being done, a larger bougie may be introduced than could
be done beforehand the process of cure is very much expedited.
But in a great number of cases where the disease is far ad-
vanced (and, generally speaking, you are not consulted till that
is the case, especially in hospital practice), you cannot resort to
the use of the bougie in the first instance, or, if you do, it must be
employed in combination with other remedies. It will be neces-
sary to lessen the irritability of the bowel by the introduction of
Brodie’s Pile
937
an opiate suppository every night, a gentle aperient being taken in
the morning. The patient may take a combination of caustic
potass with balsam of copaivi; half a drachm of balsam of copaivi,
fifteen minims of the liq. potasses, three drachms of mucil. gum
arabic, and about nine drachms of carraway water. A draught
of this composition may be taken three times a day with very
great advantage. Mr. Bryant, a respectable practitioner in the
Edgeware Road, two or three years ago recommended to me a
decoction of achillea millefolium, which I have employed in some
of these cases with manifest advantage. About two ounces of
the achillea millefolium may be put into a pint and a half of
water. This may be boiled down to a pint, of which a patient
may take a wine glass three times a day. The achillea mille-
folium is sold at the herb shops in Covent Garden; it is not in the
Pharmacopoeia, although it has been always a popular remedy.
Where abscesses have formed in the neighbourhood of the gut,
it is of no service to lay them open. I have told you on many
occasions, that if abscesses are connected with diseased structure,
they are not likely to heal; and you only make the patient worse
by laying them open, there being, of course, a much greater extent
of raw surface after the operation than before. If these ab-
scesses are to be healed at all, it can only be after the stricture
has been fully dilated.
In some cases the fseces accumulate above the stricture, the
bowel in this situation becoming distended into a large bag,
forming an immense reservoir of feculent matter, always pressing
against the stricture, and aggravating the disease. It is (p. 30)
very important to empty the bowel which is thus loaded; and
you can only do it in the following manner: — Introduce an elastic
gum catheter through the stricture into the feculent mass above;
inject tepid water, or tepid soap and water, or a weak solution of
caustic alkali; and by repeating this operation, and washing out
the gut with warm water every day, or every other day, you may
at last get the whole of the feculent accumulation dissolved, and
empty the reservoir. When this has been accomplished, the
injection of warm water should be constantly repeated, so as
to prevent the accumulation taking place again.
Medical Classics
93 8
In some cases of stricture of the rectum, I have thought that
the patient has derived benefit from the application of mercurial
ointment to the inside of the gut, which is easily managed in the
following manner: — Let the bougie be covered with lint smeared
with mercurial ointment: the bougie thus anointed must be al-
lowed to remain in the stricture for a few minutes daily.
Your success in the management of this disease will vary very
much in different cases. It will depend chiefly on the period of
the disease at which you are consulted. If it be quite in the
early stage, you may render the patient great service; and al-
though you cannot cure stricture of the rectum any more than
you can cure stricture of the urethra, yet you can dilate it, and
keep it dilated, so that the patient will suffer little from it, and
that it will not shorten his life. But if you are consulted in the
advanced stage, when the stricture is much contracted, when the
mucous membrane is ulcerated, when abscesses have formed in
the neighbourhood, you can only palliate the symptoms in some
degree. The patient under these circumstances, in spite of all
your efforts, will lead a miserable life, and in all probability will
ultimately fall a victim to the disease.
Strictures of the rectum are commonly situated in the lower
part of the gut, within the reach of the finger. Are they ever
situated higher up? I saw one case where stricture of the rectum
was about six inches above the anus; and I saw another case
where there was stricture in the sigmoid flexure of the colon, and
manifestly the consequence of a contracted cicatrix of an ulcer
which had formerly existed at this part. Every now and then,
also, I have heard from medical practitioners of my acquaintance
of a stricture of the upper portion of the rectum, or of the sig-
moid flexure of the colon, having been discovered after death.
Such cases , however , you may be assured , are of very rare occurence.
Inquire of anatomists who have been for many years teachers in
the dissecting-room, or of surgeons who have witnessed a great
number of examinations in the dead-house of an hospital, and
they will bear testimony to the correctness of what I have now
stated.
Nevertheless, an opinion has of late years prevailed among
Brodie’s Pile
939
some members of our profession, that a stricture high up in the
rectum is a very frequent cause of constipation of the bowels;
and I have known an almost incredible number of persons who
have been treated on the supposition of their labouring under
such a disease, by the introduction of long bougies into the bowel.
The only evidence of the existence of a stricture in these cases
has been, first, that there was obstinate costiveness; secondly,
that a bougie introduced into the rectum could not be made to
pass beyond a certain number of inches beyond the anus.
But what is the value of this evidence when compared with
that which anatomy affords of the rarity of this kind of stricture?
Are there not many causes of a costive state of the bowels besides
mechanical obstruction ? Will it be always easy, even in the most
healthy rectum, to introduce a bougie more than a few inches
into it? Although we call the lower bowel the rectum, you know
very well that it is any thing but a straight gut. Three or four
inches above the anus the rectum begins to make flexures, which
increase as you trace it upwards, until they terminate in the
sigmoid flexure of the colon. These flexures of the rectum differ
in different individuals, and even in the same individual at
different periods. When a bougie is introduced, be it small or
large, it is certain that it will be stopped somewhere or another by
one of these flexures; and nothing can be more unphilosophical
than to conclude, because a bougie meets with an impediment
at the distance of five or six, or eight or nine inches, that this is
the result of an organic disease of the rectum, when the natural
formation of the parts will sufficiently account for it.
But let us suppose that you actually meet with one of those
rare cases in which there is a stricture in the upper part of the
rectum; by what means are you to recognize the disease in the
living person? Or, if you can recognize it, how can you know its
exact situation? If the bougie can only be introduced to a
certain distance, how are you to be certain that it is stopped by the
stricture, and not by a fold of the bowel, or even by coming in
contact with the sacrum ?
Further than this, if you employ the force which you would
suppose to be necessary (p. 31) to make the bougie penetrate
Medical Classics
940
through the stricture, is there no danger of it penetrating the
tunics of the intestine instead? This last is no theoretical ob-
jection to the use of these long bougies in diseases of those parts.
I will not say that I have seen the patients; but I have been in-
formed on good authority of not less than seven or eight cases in
which this frightful accident occurred, and the patients died in
consequence.
Taking all these things into consideration, I advise you to
lay it down for yourselves as a rule of practice, that you should
not use bougies for stricture of the rectum, except where the
stricture is within reach of the finger. If there be any exceptions
to this rule, they are very rare indeed.
THE END
Brodie’s Tumor
Lecture on Sero-Cystic Tumors of the Breast
BY
SIR BENJAMIN BRODIE, BART.
Addressed to the Students of St. George’s Hospital, January 21, 1840. Published in
The London Medical Gazette 25: 808-814, *840
ENTLEMEN, — Although the pressure of other
engagements has caused me to resign my situa-
tion as Surgeon to St. George’s Hospital, I
shall never cease to feel the highest interest in
the welfare of an institution to which I am so
deeply indebted, nor in that of the Medical
School, which is in connection with it, and the advancement and
improvement of which has been almost the greatest object of
my life, during the last thirty years. Most gladly shall I avail
myself of any opportunity which may occur of rendering sendee
either to the one or to the other. I shall always regard the
pupils of this school as having an especial claim on my attention,
and my best wishes for their success, in the honourable practice
of an honourable and independent profession, will attend them
through life. In order that I may show that these are not mere
words of course, and that what I say is what I really feel and
niean, I have offered to the medical officers of the hospital that,
if they and you are desirous that I shall do so, I will complete
the course of gratuitous lectures which I had begun for the present
season; and that I would afterwards deliver an annual, course of
lectures, also gratuitously, in the theatre of the hospital. This
offer has been accepted, and I now proceed to redeem my promise.
But before I go farther, I must explain what these lectures are
941
Medical Classics
942
intended to be. It is evident that they cannot, as heretofore,
assume (p. 809) the form of clinical discourses. At the same
time it is desirable that they should be such as will interfere, as
little as possible, with the systematic course of lectures delivered
by Mr. Hawkins and Mr. Babington. I think that this may be
easily accomplished. Not being limited as to the time devoted
to a particular subject, I shall be enabled to discuss the history
and treatment of the diseases to which I may call your attention
at greater length, and more in detail, than can be done on ordinary
occasions. I shall sometimes, instead of treating specially of
one disease, take a particular symptom, or order of symptoms,
as the basis of our inquiries, referring them to the various diseases
from which they may arise; and I am much mistaken if this will not
enable me to communicate to you some information, which, what-
ever may be its value in the eyes of a mere morbid anatomist,
may prove useful to you when you are first engaged in the prac-
tical exercise of your professional duties. I shall, moreover, by
means of these lectures, endeavour to supply a considerable defi-
ciency of hospital education. In the wards of the hospital you
learn the great principles of disease, and the more important rules
of surgery, but you have not the opportunity of learning the whole
of what you require to know for the purposes of private prac-
tice. Diseases prevail in one class of society which in another
are only occasionally met with; and one object which I shall
keep in view is that of explaining what might otherwise per-
plex you when, passing from the bed-sides of the labouring poor,
you begin to practice your art among those who live in ease and
affluence. In the early part of my professional career it often fell
to my lot to experience the want of such instructions, and I am
inclined therefore to believe that they will not be unacceptable
to you.
The disease of which I propose to treat on the present occasion,
is an affection of the female breast. It is one of great interest in
various ways, and among others in this, that in its more ad-
vanced stages it is liable to be confounded with carcinoma,
although it is not really of a malignant nature.' And I may here
remark, that it serves very well to illustrate the observations
Brodie’s Tumor
943
which I have just made, as I should not have been able to trace
its exact history if I had trusted altogether to my hospital ex-
perience. In private practice it is of frequent occurrence. Yet
I have not met with any description of it in books corresponding
to what I have myself observed of its actual progress. You will
presently see how this is easily to be explained, by the disease
assuming a wholly new character as it proceeds, so that if you
were to look at two cases of it, one in an early, and the other in a
more advanced stage, without having witnessed the intermediate
changes which have taken place, you would be scarcely able to
recognise their identity. Let me not, however, be misunderstood
as representing that no notice whatever has been taken of it by
surgical writers. The account which Sir Astley Cooper has
given of the hydatid breast has been taken principally from cases
of this disease, and there are also some allusions to it in the
Treatise on Diseases of the Breast, lately published by M.
Velpeau.
The first perceptible indication of the disease is a globular
tumor imbedded in the glandular structure of the breast, and to
a certain extent movable underneath the skin. Sometimes there
is only one such tumor; at other times there are two or three, or
many more. The examination of the breast in the living person
does not enable you to determine the exact number which exists,
as it is only where they have attained a certain magnitude that
they are perceptible through the skin. In most instances the
disease is confined to one breast, though it is by no means very
uncommon for both breasts to be similarly affected.
The globular form which the tumor invariably assumes in the
first instance is a sufficient proof that it is formed of fluid collected
in a cyst, and of course pressing equally in every direction. If
you puncture the tumor with a grooved needle, the fluid may be
evacuated to as completely to empty the cyst, and the perfect
subsidence of it afterwards proves how little space the cyst itself
occupies. The fluid is always serous. When the tumor is small
it seems to be serum, unmixed with anything else. In a more
advanced stage of the disease, some colouring matter is generally
blended with it, and it may be green, or brown, or so dark col-
Medical Classics
944
oured as to be almost black. The quantity of fluid of course
varies. In dissection, I have found the cyst to be so small as to
contain scarcely a single drop. But it is sometimes capable of
containing several ounces. In two cases in each of which I had
the opportunity of examining a breast affected with this disease,
I found small cysts, composed of a thin membrane, and containing
serum, pervading the whole of the glandular structure, the inter-
mediate parts presenting a perfectly healthy and natural appear-
ance, and I could discover nothing more. I am, however, led to
suspect that the cysts are originally formed by a dilatation of
the lactiferous tubes. In one of the preparations now on the
table you will perceive a bristle introduced into the orifice of
one of these tubes opening on the nipple, which has passed into a
cyst (p. Sio) immediately below; and it is not uncommon to find
that by pressure on the tumor the fluid may be made to escape
by the nipple, even so as to expel the whole of it.
To complete this history of the disease, as it first shews itself,
I may add that the general health is unaffected, and that the
patient complains of no pain, unless it be that, in some instances,
there are those disagreeable nervous sensations which are apt to
arise whenever the attention is anxiously directed to any one part
of the body. I have never known the disease to occur previously
to the age of puberty, nor after the middle period of life: and, if
I am not much mistaken, it is more common in single than in
married women.
There are not a few cases in which no morbid changes take
place beyond that which I have already described; the cysts
remaining unaltered, or only slowly increasing in size during the
remaining of the patient’s life. But in other cases the tumors
lose their globular form, and a solid substance is deposited in the
breast, connecting different cysts with each other in one large
mass of disease. This process may be going on for many suc-
cessive years without inducing pain or much inconvenience,
except what belongs to the bulk of the tumor. But the period
at last arrives when other changes take place, the disease assum-
ing a more formidable and dangerous character. The skin, in
some one part, more tense and thin than elsewhere, becomes
Brodie’s Tumor 945
inflamed and ulcerates; and an intractable and bleeding ulcer is
the consequence. Then one of the cysts, more distended than
the rest, gives way, discharging its serous contents. Perhaps
the opening heals, then again gives way; and this may recur
several times, until at last a fungous growth protrudes through
the opening. And here the question arises, what is the exact
nature of these changes, which, by a slow gradual operation, at
last convert a disease so small and simple in its origin, into one so
extensive and complicated? This I shall next endeavour to
explain; and a series of preparations on the table, with the his-
tories of the cases belonging to them, will enable me to do so.
The first of these is a membranous cyst, which I removed from
the breast of a private patient. It is of the size of a large walnut;
and you will observe that about one-fourth part of its cavity is
occupied by an irregularly shaped excrescence attached to one
portion of its internal surface.
Several years ago Mr. Green and myself were present when
Mr. Freeman, of Spring Gardens, removed the breast of a female
with a similar tumor imbedded in it. The tumor was of about the
same size as that which I have iust shewn you; and in my notes
of the case I find it stated, that “the cyst contained serum, but
that about one-third part of its cavity was occupied by an ex-
crescence which came from one part of its inner surface. The
excrescence had the appearance of fibrine which had become
vascular.”
The history of the patient whose case has furnished us with
the next preparation, and the accompanying drawing, is highly
interesting, and illustrates many circumstances connected with
this disease.
This lady consulted me in the month of October 1837, respect-
ing a tumor of the breast, which might be compared as to size
to a large nutmeg. It was of a globular shape, and evidently
contained fluid. I punctured it with a grooved needle, and a
yellow serum escaped. There were no other indications of dis-
ease. Afterwards I made a free opening into the cyst with a
lancet, and, the whole of the fluid having been evacuated, I
introduced a piece of lint, with a view to produce inflammation
Medical Classics
946
and the formation of granulations on its inner surface, which
might obliterate its cavity. An abundant suppuration and a
good deal of inconvenience followed this trifling operation. At
the end of about two months, although the abscess was not
properly closed, the patient believing herself to be nearly well,
left London of her own accord. I heard nothing of her from this
time until, after the lapse of about fifteen months, she again
placed herself under my care. In the situation of the cyst which
I had laid open there was now a considerable solid tumor, a
portion of which, of about half the size of an orange, projected
through an opening in the skin, forming an irregularly shaped
fungus. There seemed to be no other remedy than that of the
removal of the breast by an operation, to which the patient will-
ingly consented; and from which she recovered favourably.
On examining the tumor in its recent state some remains of the
original membranous cyst, containing a small quantity of serum,
were found at its basis. A large quantity of solid substance pro-
jected as an excrescence from the inner surface of the cyst,
assuming a peculiar plicated or fimbriated appearance, and a
portion of this excrescence protruding through the skin, formed
the external fungus. You will see these appearances distinctly
visible in the preparation, although not so plainly as before the
parts were immersed in alcohol, and they are well represented in
this drawing, which is made with Mr. Perry’s usual accuracy.
The structure of the morbid growth seems to be of the simplest
kind. I can compare it to nothing better than fibrine imperfectly
organized, (p. 81 1) Its existence does not seem to be limited to
the inside of the cyst, a considerable mass being on the outside,
in immediate contact with the gland of the breast. Previously
to the operation the remaining part of the breast appeared to
be in a healthy condition; but on dissection afterwards I found
imbedded in it a great number of membranous cysts, of various
sizes, from that of a pea to that of a horsebean. These cysts
contained a transparent yellow serum, and were evidently of the
same nature with the larger cyst which I had formerly punctured,
and in which the fungus had originated afterwards.
The preparation which I now shew you leads me to the history
Brodie’s Tumor 947
of a patient who is still under the care of Mr. Keate, in this
hospital. Fifteen months ago, being then an out-patient, she
had a tumor of the left breast, above the nipple, of the size of a
walnut. It was globular and moveable. Mr. Cutler punctured
it with a grooved needle, and ascertained that it contained serum.
Soon afterwards it was found that a fluid, similar to that which
had escaped by the puncture, was discharged by the nipple.
From this time the tumor gradually increased to size. Six weeks
ago Mr. Keate repeated the puncture with a needle, giving exit
to a large quantity of yellow serum. The tumor, in consequence,
was much reduced in size, but it soon enlarged again, so as to
exceed its former dimensions. On the 21st of last December,
Mr. Keate made an incision into it, and the cyst was now so
capacious that not less than half a pint of serum was evacuated
by the wound. The serum now was tinged with blood, and a
good deal of haemorrhage followed the operation. In the course
of a few days a large dark-coloured fungus was seen projecting
through the wound. Under these circumstances, on the second
of present month, Mr. Keate amputated the breast, and you
may here see the morbid appearance which it presents.
The tumor consists of a large membranous cyst, which might
have been capable of containing twelve ounces of fluid, if the
greater part of its cavity had not been occupied by a great number
of excrescences attached to its inner surface. These excrescences
vary in size, the smallest being not bigger than a pea, while one
of them is of the size of a small orange. They are covered by a
thin membrane, which appears to be continuous with, and a
reflection of the inner layer of the cyst. When cut into, these
excrescences present the appearance of a considerable variety of
structure. Some of them may be compared to recently coagu-
lated albumen not yet organized: others, to imperfectly organized
fibrine: some of them have an apparent resemblance to fatty
tumors, although I do not find that they actually contain any
oily matter, and one of them might , on the first view of it, be
almost mistaken for medullary disease.
The tumor which is displayed in the next preparation illus-
trates a still more advanced stage of the disease. I removed it
Medical Classics
948
from the breast of a private patient in the month of November
1836. It had existed for many years gradually, but slowly in-
creasing in size. You perceive that at the time of its removal the
, tumor was not larger than a small orange, and that it was of an
irregular shape. Near the base of the nipple is a membranous
cyst, which contained two or three drams of very dark-coloured
serum. Some smaller cysts, which also contained serum, are
seen in the neighbourhood, and a bristle introduced at one of the
ducts of the nipple has entered one of the cysts by a smaller
circular aperture. The seat of the tumor, on a superficial view
of it, appears to be one uniform mass of solid substance: but on
a more close inspection you find it to consist of a congeries of
membranous cysts, the cavities of which are completely filled
with fibrinous matter. In many of the cysts, on examination with
a probe, I found this fibrinous matter to have an attachment to
one part of the inner surface, lying in contact with the lining
membrane elsewhere, but having no actual adhesion to it.
We can scarcely doubt that if in this case the operation had
been deferred until a later period, the growths of fibrinous matter,
by which the cysts were occupied, would have contracted uni-
versal adhesions to the membrane with which they lay in contact,
and that the whole, with the exception of those cysts which still
contained serum, would have been identified in one solid mass of
substance, in which the original cellular or cystic structure would
have entirely disappeared. Of this last change, the preparation
which I now shew you, seems to furnish an example. The
patient from whom this specimen was taken was under my care
in the year 1818. I have no notes of the early history of the
case; but the disease had probably been of long duration, as, at
the time of my being consulted, the breast had attained an
enormous size, being not less than seven pounds in weight. She
was a middle-aged person, otherwise in good health, and the skin
and the axillary glands were free from disease. Under these
circumstances the diseased breast was amputated. The wound
healed favourably, and I heard of the patient being alive and well
several years afterwards. If you examine the cut (p. 81a) surface
of the tumor, or rather of that portion of it which is displayed in
Brodie’s Tumor 949
the preparation, you will see that the greater part of it is one
uniform solid mass, of which it is difficult to describe the structure
in words, further than by saying, that in some parts it has an
indistinct laminated appearance. There are, however, in one
part of it, several membranous cysts of various dimensions, which,
when first cut into, were found containing serum. One of those
is distinguished from the rest by its greater size, being capable of
containing several ounces of fluid, but being also occupied by a
large excrescence attached to one part of its inner surface, and
projecting into its cavity. This excrescence is of an irregular
shape, very similar in appearance to some of those which you
have seen in the other preparations. In its recent state it seemed
to consist of distinct masses of recently coagulated albumen, semi-
pellucid, some of a light yellow, others ✓approaching to a purple
colour, and altogether bearing no small resemblance to a bunch
of white and purple grapes. These peculiar appearances, of
course, have been destroyed by the immersion in alcohol.
Having explained to you these facts in detail, with a view to
impress the subject more completely on your minds, I shall
endeavour to trace, in a few words, the pathological history which
they seem to establish, and which, not only as a matter of science,
but in a practical point of view, it is so important for you to
understand. It appears, then, to be as follows: —
First: a greater or less number of membranous cysts are gen-
erated in the breast, containing serum. The latter is at first of
a light yellow colour, and transparent, but afterwards becomes
of a darker colour, and opaque. There is reason to believe that
these cysts are formed by a dilatation of portions of some of the
lactiferous tubes.
Secondly: morbid growths or excrescences are generated from
the inner surface of one or more of these cysts, projecting into
their cavities. These excrescences seem to consist of albumen or
fibrine, which, after some time, (if not immediately) becomes
organized. They are covered by a thin delicate membrane,
which seems to be reflected over them for the inner surface of
the cyst; but whether they are originally formed between two
layers of the membrane of the cyst, or whether they are at first
950 Medical Classics
mere deposits of fibrine or albumen on the inner surface of the
cyst, a thin membrane being formed on their surface afterwards,
remains to be determined by future observations.
Thirdly: there is some reason for believing that a similar growth
of fibrinous substance may take place from the external surface
of the cysts connecting different cysts with each other; but this
point may perhaps require to be illustrated by further investi-
gations.
Fourthly: under certain circumstances the cysts become com-
pletely filled up by the morbid growths, so that their cavities are
obliterated, the tumor being thus converted into a solid mass,
in which, however, the remains of the cysts are perceptible; and
this is the prelude to a still further change, in which the greater
part of the cysts have wholly disappeared, a solid mass of an
indistinctly laminated texture occupying their place.
Fifthly: if one of the membranous cysts be artificially laid
open, or if it burst from over-distension with serum, the fibrinous
excrescence from its inner surface being no longer restrained by
the pressure of the skin, increases in size, and protrudes ex-
ternally in the form of a fungus, giving to the tumor a new and
more formidable character.
In this last stage of the disease, it is evident that spreading
ulceration, sloughing, and haemorrhage, the usual results of an
ulcer occurring in a diseased structure, must ensue, and that no
remedy is likely to be of any service to the patient, except the
removal of the affected parts by a surgical operation.
And this leads us to the concluding and most important part
of these inquiries. In considering the treatment of these cases,
it is convenient to distinguish those in which the disease is still
in its earliest stage, presenting itself in the form of a membranous
cyst, or cysts, containing serum, from those in which the growth
of a solid fibrinous substance has became superadded to this
simple original structure.
In the first order of cases we may venture to evacuate the fluid
contents of the cyst by penetrating it with a grooved needle.
No inconvenience is ever the result of this trifling operation;
and it is often useful by assisting us in our diagnosis, and also by
Brodie’s Tumor
95i
enabling us to determine whether any growth of solid matter, in
connection with the cyst, has yet taken place. But it is not
productive of any permanent benefit, as the fluid is always
regenerated in the course of two or three days. I have no ex-
perience which would lead me to recommend any further or more
considerable operation than this. It is needless to remove what
appears to be a solitary cyst, as it is always highly probable that
there are other cysts in other parts of the breast co-existent with
it, which are not yet sufficiently developed to be perceptible
through the skin; or othenvise, that such cysts will be formed
afterwards if they do not exist already. As to the removal of the
entire breast, it is, under these circumstances, an unjustifiable
proceeding, unless it be in a (p. 873) few cases in which the cyst
or cysts have attained so large a size as to be inconvenient from
their bulk. The disease, in its early stage, causes no suffering,
and may remain for years, or for the whole of the patient’s life,
without advancing farther, and, under these circumstances, no
harm can possibly arise from delay. Besides: if I am not greatly
mistaken, there is a simple and safe mode of treatment which
may often be employed with great advantage, and which is not
open to those objections to which any severe operation is always
liable.
Some years ago, a lady consulted me concerning a small tumor
of the breast, near the nipple, and apparently containing fluid.
Not at that time knowing any thing better, I recommended that
it should be removed by the knife. The day was fixed for the
operation, but, in the meantime, some domestic circumstance
occurred which made it necessary that it should be postponed.
Under these circumstances I proposed to the patient that she
should make the experiment of applying a stimulating embroca-
tion to surface of the skin. This accordingly was done, and the
result was, that the tumor disappeared. Some time afterwards,
another lady consulted me, having a globular tumor of one breast,
larger than a pigeon’s egg. I punctured it with a grooved needle,
and a considerable quantity of serum was drawn off. In a few
days, the fluid being re-produced, the tumor, which had wholly
disappeared, was as large as ever. I now applied the same treat-
Medical Classics
952
ment as in the former case; and in the course of some weeks the
whole of the fluid had become absorbed, and nothing was per-
ceptible, except a slight thickening, apparently formed by
the collapsed membrane of the cyst. The thickening disap-
peared gradually, and when I last saw the patient, three or four
years after the time which I have mentioned, there had been
no recurrence of the disease. Since these cases occurred, I have
had recourse to the same method of treatment in many instances.
In some of them the result has been, that the tumor or tumors
have entirely disappeared; in others, that without disappearing
altogether, they have become very much reduced in size; and it
is only in a few instances in which the treatment was not very
rigidly pursued, that it has been productive of no manifest
advantage.
The application which I have generally made use of on these
occasions is the following: —
II Spiritus Camphorati, Spiritus tenuioris, aa. giiiss; Liquoris
plumbi diacetatis, gj- fiat Embrocatio.
I have directed the patient to soak a piece of flannel in this em-
brocation, and to apply it so as to cover that part of the breast
in which the tumor is situated, renewing the application six or
eight times in the day and night until the skin becomes inflamed;
then to omit the application for two or three days, but to resume
the use of it as soon as the inflammation has subsided. The
period of time during which it is necessary to pursue this method
of treatment varies in different cases. In some, all that can be
desired is accomplished in the course of three or four weeks;
in others, it must be continued, with occasional intermissions,
for some months. Other stimulating applications may be occa-
sionally substituted for that which I have just mentioned. Sev-
eral blisters may be applied in succession; each of them being
kept open for a few days with the savine cerate; or a solution of
gj- of iodine in gj- of alcohol may be applied to the skin once or
twice daily, by means of a large camel’s-hair brush. On the
whole, however, I am led to believe, that the embrocation is
more efficient than any thing else.
Brodie’s Tumor
953
But these remedies are of no avail when the growth of solid
substance is begun. In this more advanced period of the disease,
no good is to be expected except from the removal of the entire
breast; and such an operation may be had recourse to with every
prospect of success.
The disease seems to be entirely local. It belongs to the
breast, and to nothing else. It does not contaminate either the
skin or the lymphatic glands; it is not complicated with any cor-
responding disease of the viscera; and all the experience which
I have had justifies the conclusion, that if care be taken that no
portion of the breast is allowed to remain, there is no danger of
its recurrence.
A careful observer will find little difficulty in distinguishing
cases of this disease from those of the other diseases to which the
breast is subject. It is, however, desirable with a view to a
more ready and accurate diagnosis, that we should consider
what are the diseases with which it is most liable to be con-
founded. The principal of these are as follows: —
First: a thin membranous cyst, containing a transparent watery
fluid, without coagulable matter, is occasionally found in the
breast, which may be compared to the membranous cysts, con-
taining pure water, which are sometimes met with in connexion
with the liver; and of which I have published some cases in one
of the medical journals*; and to the encysted (p. 84) hydrocele
of the spermatic cord or testicle. This disease is probably rare,
as only two examples of it have fallen under my observation.
In one of them the cyst was extracted by an operation; in the
other the nature of the fluid having been ascertained by means
of a puncture with a grooved needle, the tumor afterwards dis-
appeared under the use of a stimulating embrocation.
Secondly: a cavity is sometimes formed in the breast, contain-
ing one or more genuine hydatids. Here there is a single fluctuat-
ing tumor, which gradually increases to a large size. If it be
freely opened, the hydatids escape, and the cavity in which they
were lodged becomes an abscess, which slowly closes and heals.
Thirdly: in a more advanced stage of the disease, it is not un-
* See Medical Gazette, vol. i, page 344; and voL xv, page 25.
Medical Classics
954
frequently mistaken for carcinoma; and I have no doubt that a
large proportion of the cases in which it has been supposed that an
operation has effected a permanent cure of the last-mentioned
disease, have been in reality of this description.
I have hitherto confined myself to the description of the origin,
progress, and treatment, of this disease of the breast, without
venturing to give it a name.
It is, however, necessary that we should have the means of dis-
tinguishing it in conversation and in writing; and I would sug-
gest “the sero-cystic tumor of the breast” as being an appropriate
appellation — preferable, at all events, to a mere arbitrary term;
inasmuch as it expresses with sufficient precision the character
which the tumor possesses in its origin.
THE END
MEDICAL CLASSICS
VOL. 2 June, 1938 NO. IO
CONTENTS
Portrait of James Parkinson ------- 9 56
Biography ----------- - 957
Eponyms - -- -- -- -- -- - 958
Bibliography of Writings ------- 958
Biographies - -- -- -- -- -- 961
Index to Bibliography --------961
An Essay on the Shaking Palsy James Parkinson 964
Index - -- -- -- -- -- -- - 998
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MEDICAL CLASSICS
vol . i June, 1938 no . 10
James Parkins.on
BIOGRAPHY
1755 April 11, bom, and on April 29, baptized and registered in
St. Leonard’s Shoreditch Parish Register, Middlesex.
Son of Jno. Parkinson, surgeon, who died in 1784.
Lived at No. 1 Hoxton Square, London.
1781 Age 26. Married Mary Dale in St. Leonard’s Shoreditch
Church on May 21. Had three sons, one a doctor, and
two daughters.
1785 Age 30. In active practice and attended Hunter’s course
of lectures on surgery.
1794 Age 39. Examined on oath before the privy council in
connection with the so-called “Pop-gun Plot” to assas-
sinate George III. He admitted being a member of the
Committee of Correspondence of the London Corre-
sponding Society and of the Constitutional Society.
1807 Age 52. _ Original member of the Geological Society on its
foundation.
1817 Age 62. Wrote An Essay on the Shaking Palsy.
1824 Age 69. Died Dec. 21, in Kingsland Road, only a short
distance from where he had always lived. Buried in
Hoxton Parish burying ground, the church yard of St.
Leonard’s Shoreditch church. No stone can now be
found.
Also:
Fellow of Royal College of Surgeons.
Member of the Wemerine Society of Edinburgh.
Member of the Caesarean Society of Moscow.
957
Medical Classics
9 58
He was a man of the Old Master type described by Holmes,
rather than the highly specialized scarabaeist. Master of medi-
cine, chemistry, geology, paleontology and oryctology, he was a
writer of many textbooks, great as a compilator, keen in observa-
tion and desirous of seeing everything named and placed in its
proper class. (Rowntree).
EPONYMS
Disease or Syndrome: Paralysis agitans or shaking palsy: a
disease of late life, progressive in its course, and marked by a
characteristic tremor of the muscles, weakness, delay of
voluntary motion, a peculiar festinating gait, and muscular
contraction, causing peculiar and characteristic positions of
the limbs and head. The disease is attended with excessive
sweating and feelings of heat and cold. (Dorland)
Facies or Sign: A stolid expression of the face, characteristic of
paralysis agitans.
BIBLIOGRAPHY OF WRITINGS
A — Army Medical Library.
B — New York State Library.
C — New York Academy of Medicine Library.
1. Observations on Dr. Hugh Smith’s Philosophy of physic.
Anonymous but ascribed to James Parkinson, 1780.
a. Revolution without bloodshed; or reformation preferable to
revolt. Pamphlet, 1794.
3. A vindication of the London Corresponding Society. Pam-
phlet, 1794.
4. Assassination of the King. A letter to Mr. John Smith,
I7 95-
5. The chemical pocket-book; or memoranda chemica; arranged
in a compendium of chemistry. 1799. 1. ed., 12 0 .
(Same) 1799. 1. Amer. ed. (Same) 1801. 2. ed. (Same)
Philadelphia, Humphrey, 1802. xii, 215 pp., 2 pi. from
the London 2 ed. of 1801. In A and C. (Same) 1803. 3.
ed. (Same) 1809. 4. ed.
James Parkinson 959
6. Medical admonitions to families respecting the preservation
of health and the treatment of the sick. Also, a tablet of
symptoms, serving to point out the degree of danger, and
to distinguish one disease from another; with observations
on the improper indulgence of children. 1799. 1. ed., 12 0 .
(Same) London, Whittingham, 1801. 4. ed., 1 2 0 , 35 1.,
548 pp. In C. (Same) Portsmouth, N. H., Pierce, 1802.
1. Amer. from 4. London ed., 8°, 520 pp. In A, B and C.
(Same) London, Symonds, 1807. 5 ed., 8°, xx, 503 pp.
In A.
7. Dangerous sports; a tale addressed to children. 1800. 1.
ed., 1 6°. (Same) 1808. 2. ed.
8. The hospital pupil; or, observations addressed to the parents
of youths intended for the profession of medicine and
surgery; on their previous education, pecuniary resources,
and on the order of their professional studies, with hints
to the young pupil on the prosecution of hospital studies,
on entering into practice, and on medical jurisprudence.
London, Symonds, 1800. 16 0 , 159 pp. In C. (Same)
London, Sherwood, 1817. 2. ed., 12 0 , 208 pp. In A.
9. The villager’s friend and physician; or a familiar address on
the preservation of health, and the removal of disease on
its first appearance; supposed to be delivered by a village
apothecary, with cursory observations on the treatment of
children, on sobriety, industry, etc. London, Sammells,
1800. 12 0 , 85 pp. In C. (Same) London, Whittingham,
1804. 2. ed., 12 0 , 71 pp., 1 pi. In A.
10. Hints for the improvement of trusses; intended to render their
use less inconvenient, and to prevent the necessity of an
understrap. With the descripton of a truss of easy con-
struction and slight expense, for the use of the laboring
poor. London, Symonds, 1802. 8°, viii, 9-22 pp., 1 pi.
In A.
n. The way to health. 1802. 8°.
12. Organic remains of a former world; an examination of the
mineralized remains of the vegetables and animals of the
antediluvian world; generally termed extravenous fossils.
Vol. 1, 1804; 2, 1808; 3, 1811.
960 Medical Classics
13. Observations on the nature and cure of gout; on nodes of
the joints; and on the influence of certain articles of diet,
in gout, rheumatism and gravel. London, Symonds, 1805.
• 8°, viii, 174 pp. In A and C.
14. Remarks on Mr. Whitebread’s plan for the education of the
poor. 1807. 8°.
1 5. Observations on the excessive indulgence of children. 1 807.
8 °.
16. Mad-houses. Observations on the act regulating mad-
houses, and a correction of the statements in the case of
Benjamin Elliott, convicted of illegally confining Mary
Daintree; with remarks addressed to the friends of insane
persons. London, Whittingham and Rowland, 1811. 8°,
vii, 48 pp. In A and B. Also, rev.: Edinb. Med. Jour.,
7 : 371-377, 1811.
17. A case of trismus, successfully treated. By John Parkinson,
communicated by James Parkinson. Read June 18, 1811.
Med.-Chir. Trans., 2: 291-295, 1811.
18. Case of diseased appendix vermiformis. By John Parkinson,
communicated by James Parkinson. Read Jan. 21, 1812.
Ibid., 3: 57 -58, 1812. Also: reference, 4 lines, Edinb.
Med. Jour., 9: 198, 1813.
19. An essay on the shaking palsy. London, Whittingham and
Rowland, 1817. 12 0 , iv, 66 pp. In A and C. (Same)
Facsimile ed., Amer. Med. Assn. Press, Chicago, 1917.
Also: Arch. Neur. and Psych., 7: 681-710, 1922. .
20. Outlines of Oryctology. 1822. 340 pp. Passed through 3
editions.
21. John Hunterian Reminiscences — transcribed by James Park-
inson. Edited by his son, J. W. K. Parkinson. London,
1 833. 4 0 . In A.
22. Also author of several geological papers in Nicholson’s
“Journal”, 1809-1812, and in the first, second and fifth
volumes of the Geological Society’s Transactions, 18 1 1-
1818.
g6i
James Parkinson
BIOGRAPHIES
Biography by G. S. Boulger. Diet. Nat. Biog., 4 3: 314, 1895.
Biography by L. G. Rowntree. Johns Hopk. Hosp. Bull., 23:
33 - 45 . l 9 12 '
James Parkinson and his essay on paralysis agitans. By R. T.
Williamson. Janus, Leyde, 29: 193-197, 1925.
Note on history of appendicitis in children. By J. Ruhrah.
Amer. Jour. Dis. Child., 49: 474-476, 1935.
INDEX TO BIBLIOGRAPHY
Reference Year
Appendix vermiformis 18 1812
Assassination of the King 4 1795
Chemical pocket-book 5 1799
Children, indulgence of 15 1807
Dangerous sports 7 1800
Gout 13 1805
Hospital pupil 8 1817
Hunterian reminiscences 21 1833
London Corresponding Society 3 1794
Mad-houses 16 1811
Medical admonitions 6 I 799
Organic Remains 12 1804
Oryctology 20 1822
Palsy, shaking 19 1817
Revolution 2 1794
Smith’s, Dr., philosophy 1 1780
Trismus 17 1811
Trusses 10 1802
Villager’s friend 9 1800
Way to health II 1802
Whitebread’s, Mr., plan 14 I ^°7
INTRODUCTION
James Parkinson had written on several medical subjects before
he published An essay on the shaking palsy in 1817. He had
reported in 1812 the first case of appendicitis in English, this case
being also the first in which perforation was recognized as the
cause of death. (H. A. Kelly.) He had published several books
of medical advice for the layman, Medical admonitions to families
, Dangerous sports . . ., 'The hospital pupil ; or, observations
addressed to the parents of youths intended for the profession of medi-
cine and surgery . . ., and The villager's friend and physician . .
But James Parkinson is remembered today because of the condi-
tion which is now known by his name, Parkinson’s disease or
shaking palsy.
Parkinson himself tells us in the Essay that different forms of
tremors had been noted by Galen, Sylvius de la Boe, Juncker,
Cullen and Sauvages. The author quotes freely in Latin from
these earlier writers and points out differences in their descriptions
and conceptions of types of tremors. He thus shows that he was
acquainted with medical literature and had a good education.
Why has this Essay covering only 66 small pages brought fame
to its writer? The answer is found in the clear, exact, and com-
plete picture of the disease syndrome which Parkinson gives us.
The reader can see vividly the patients described, their character-
istic tremor, posture and gait. The course of the disease is
dramatic in its description. Several case records follow. The
author then discusses varieties of tremor, palpatations and con-
vulsions, and explains how the disease differs from others with
which it is most easily confused. Parkinson attempts to give
some etiologic factors such as trauma and disease of the medulla
spinalis but he regrets that lack of autopsy study prevents him
from knowing the pathologic changes in the brain. Therefore he
knows little of the etiology or true nature of the condition.
Finally the treatments recommended are interesting from an
historical viewpoint, i.e., bleeding, blisters, vesicatories and mak-
ing an issue with caustic. At no point does Parkinson describe
the characteristic facies or “mask” which has become associated
with his name.
Because of the interest which Parkinson aroused in the shaking
palsy (he tells us this was the chief aim in writing the Essay ) ,
considerable advance has been made in the knowledge of the patho-
logic processes. It is now recognized that there is a degeneration
of the globus pallidus and ansa lenticularis with disappearance of
ganglion cells and fibers, increase of glia fibers, softening and la-
cunar formations (Wechsler). Other pathologic changes have
been found in other parts of the brain and the subject is still
controversial. (Jour. Amer. Med. Assn., 100:1602-1603, 1933.)
Recently much interest has grown up around the so-called
parkinsonian syndrome, it being recognized that many of the signs
described by Parkinson follow encephalitis. These cases, of
course, come on acutely, usually in young people and reveal signs
of inflammation, frequently in the substantia nigra and midbrain
structure. Acute cases also may follow hemorrhage into the basal
ganglion or syphilis in this region. Chronic cases of the syndrome
occur with neoplasms or arteriosclerosis. Relation of trauma to
the syndrome was studied in 1932 by Naville and de Morsier and
by Minovici, Paulian and Stanesco; they all conclude that in some
cases trauma may be an indirect etiologic factor.
Parkinson wrote a valuable article in 1817; 121 years later we
know a little more of the condition but there is much more to be
learned. Only careful study and research will bring forth the
ultimate answer to the problems still present.
An Essay on the Shaking Palsy
BY
JAMES PARKINSON
Member of the Royal College of Surgeons
London: Printed by Whitringham and Rowland, Goswell Street,
for Sherwood, Neely, and Jones, Paternoster Row, 1817
*
Preface
HE advantages which have been derived from
the caution with which hypothetical statements
are admitted, are in no instance more obvious
than in those sciences which more particularly
belong to the healing art. It therefore is neces-
sary, that some conciliatory explanation should
be offered for the present publication: in which, it is acknowl-
edged, that mere conjecture takes the place of experiment; and,
that analogy is the substitute for anatomical examination, the
only sure foundation for pathological knowledge.
When, however, the nature of the subject, and the circum-
stances under which it has been here taken up, are considered,
it is (p. ii) hoped that the offering of the following pages to the
attention of the medical public, will not be severely censured.
The disease, respecting which the present inquiry is made, is of
a nature highly afflictive. Notwithstanding which, it has not
yet obtained a place in the classification of nosologists; some have
regarded its characteristic symptoms as distinct and different
diseases, and others have given its name to disease differing es-
964
Shaking Valsj 965
sen daily from it; whilst the unhappy sufferer has considered it as
an evil, from the domination of which he had no prospect of
escape.
The disease is of long duration: to connect, therefore, the
symptoms which occur in its later stages with those which mark
its commencement, requires a continuance of observation of the
same case, or at least a correct history of its symptoms, even for
several years. Of both these advantages the writer has had the
opportunities of availing (p. iii) himself; and has hence been led
particularly to observe several other cases in which the disease
existed in different stages of its progress. By these repeated
observations, he hoped that he had been led to a probable con-
jecture as to the nature of the malady, and that analogy had sug-
gested such means as might be productive of relief, and perhaps
even of cure, if employed before the disease had been too long
established. He therefore considered it to be a duty to submit
his opinions to the examination of others, even in their present
state of immaturity and imperfection.
To delay their publication did not, indeed, appear to be war-
rantable. The disease had escaped particular notice; and the
task of ascertaining its nature and cause by anatomical investi-
gation, did not seem likely to be taken up by those who, from
their abilities and opportunities, were most likely to accomplish
it. That these friends to humanity (p. iv) and medical science,
who have already unveiled to us many of the morbid processes
by which health and life is abridged, might be excited to extend
their researches to this malady, was much desired; and it was
hoped, that this might be procured by the publication of these
remarks.
Should the necessary information be thus obtained, the writer
will repine at no censure which the precipitate publication of
mere conjectural suggestions may incur; but shall think himself
fully rewarded by having excited the attention of those, w r ho may
point out the most appropriate means of relieving a tedious and
most distressing malady.
966
Medical Classics
CONTENTS
Definition — History — Illustrative Cases , 1
Chap. II
Pathognomonic Symptoms Examined — Tremor Coactus — Scelo-
tyrbe Festinana 19
Chap. Ill
Shaking Palsy Distinguished From Other Diseases With Which It
May Be Confounded 27
Chap. IV
Proximate Cause — Remote Causes — Illustrative Cases 33
Chap. V
Considerations Respecting The Means Of Cure 56
Chapter I. Definition — History — Illustrative Cases
SHAKING PALSY (PARALYSIS AGITANs)
(Involuntary tremulous motion, with lessened muscular power, in
parts not in action and even v'hen supported; with a propen-
sity to bend the trunk forwards, and to pass from a walking
to a running pace: the senses and intellects being uninjured)
The term Shaking Palsy has been vaguely employed by medi-
cal writers in general. By some it has been used to designate
ordinary (p. 2) cases of Palsy, in which some slight tremblings
have occurred; whilst by others it has been applied to certain
anomalous affections, not belonging to Palsy.
The shaking of the limbs belonging to this disease was partic-
ularly noticed, as will be seen when treating of the symptoms, by
Galen, who marked its peculiar character by an appropriate term.
The same symptom, it will also be seen, was accurately treated
of by Sylvius de la Boe. Juncker also seems to have referred to
this symptom: having divided tremor into active and passive,
he says of the latter, "ad affectus semiparalyticos pertinent;
de qualibus hie agimus, quique tremores paralytoidei vocantur.”
Tremor has been adopted, as a genus, by almost every nosologist;
but always unmarked, in their several definitions, by such char-
Shaking Palsy 9 67
acters as would embrace this disease. The celebrated Cullen,
with his accustomed accuracy observes, "Tremorem, utpote
semper symptomaticum, in numerum generum recipere nollem;
species autem a Sauvagesio recensitas, prout mihi vel astheniae
vel paralysios, vel convulsionis symptomata esse videntur, (p. 3)
his subjungam*. Tremor can indeed only be considered as a
symptom, although several species of it must be admitted. In
the present instance, the agitation produced by the peculiar
species of tremor, which here occurs, is chosen to furnish the
epithet by which this species of Palsy, may be distinguished.
HISTORY
So slight and nearly imperceptible are the first inroads of this
malady, and so extremely slow is its progress, that it rarely hap-
pens, that the patient can form any recollection of the precise
period of its commencement. The first symptoms perceived are,
a slight sense of weakness, with a proneness to trembling in some
particular part; sometimes in the head, but most commonly in
one of the hands and arms. These symptoms gradually increase
in the part first affected; and at an uncertain period, but seldom
in less than twelve months or more, the morbid influence is felt
in some other part. Thus assuming one of the (p. 4) hands and
arms to be first attacked, the other, at this period becomes simi-
larly affected. After a few more months the patient is found to
be less strict than usual in preserving an upright posture: this
being most observable whilst walking, but sometimes whilst sit-
ting or standing. Sometime after the appearance of this symp-
tom, and during its slow increase, one of the legs is discovered
slightly to tremble, and is also found to suffer fatigue sooner than
the leg of the other side: and in a few months this limb becomes
agitated by similar tremblings, and suffers a similar loss of power.
Hitherto the patient will have experienced but little incon-
venience; and befriended by the strong influence of habitual en-
durance, would perhaps seldom think of his being the subject of
disease, except when reminded of it by the unsteadiness of his
hand, whilst writing or employing himself in any nicer kind of
* Synopsis Nosologiae Methodicae. Tom. ii- p. 19c.
Medical Classics
968
manipulation. But as the disease proceeds, similar employments
are accomplished with considerable difficulty, the hand failing to
answer with exactness to the dictates of the will. Walking (p. 5)
becomes a task which cannot be performed without considerable
attention. The legs are not raised to that height, or with that
promptitude which the will directs, so that the utmost care is
necessary to prevent frequent falls.
At this period the patient experiences much inconvenience,
which unhappily is found daily to increase. The submission of
the limbs to the directions of the will can hardly ever be obtained
in the performance of the most ordinary offices of life. The
fingers cannot be disposed of in the proposed directions, and ap-
plied with certainty to any proposed point. As time and the
disease proceed, difficulties increase: writing can now be hardly
at all accomplished; and reading, from the tremulous motion,
is accomplished with some difficulty. Whilst at meals the fork
not being duly directed frequently fails to raise the morsel from
the plate: which, when seized, is with much difficulty conveyed
to the mouth. At this period the patient seldom experiences a
suspension of the agitation of his limbs. Commencing, for in-
stance in one arm, the (p. 6) wearisome agitation is borne until
beyond sufferance, when by suddenly changing the posture it
is for a time stopped in that limb, to commence, generally, in
less than a minute in one of the legs, or in the arm of the other
side. Harassed by this tormenting round, the patient has re-
course to walking, a mode of exercise to which the sufferers from
this malady are in general partial; owing to their attention being
thereby somewhat diverted from their unpleasant feelings, by
the care and exertion required to ensure its safe performance.
But as the malady proceeds, even this temporary mitigation
of suffering from the agitation of the limbs is denied. The pro-
pensity to lean forward becomes invincible, and the patient is
thereby forced to step on the toes and fore part of the feet, whilst
the upper part of the body is thrown so far forward as to render
it difficult to avoid falling on the face. In some cases, when this
state of the malady is attained, the patient can no longer exercise
himself by walking in his usual manner, but is thrown on the
Shaking Palsy 969
toes and forepart of the feet; being, at the same (p. 7) time,
irresistibly impelled to take much quicker and shorter steps, and
thereby to adopt unwillingly a running pace. In some cases it
is found necessary entirely to substitute running for walking;
since otherwise the patient, on proceeding only a very few paces,
would inevitably fall.
In this stage, the sleep becomes much disturbed. The trem-
ulous motion of the limbs occur during sleep, and augment until
they awaken the patient, and frequently with much agitation
and alarm. The power of conveying the food to the mouth is
at length so much impeded that he is obliged to consent to be fed
by others. The bowels, which had been all along torpid, now,
in most cases, demand stimulating medicines of very considerable
power: the expulsion of the faeces from the rectum sometimes
requiring mechanical aid. As the disease proceeds towards its
last stage, the trunk is almost permanently bowed, the muscular
power is more decidedly diminished, and the tremulous agitation
becomes violent. The patient walks now with great difficulty,
and unable any longer to support himself (p. 8) with his stick, he
dares not venture on this exercise, unless assisted by an attend-
ant, who walking backwards before him, prevents his falling for-
wards, by the pressure of his hands against the fore part of his
shoulders. His words are now scarely intelligible; and he is not
only no longer able to feed himself, but when the food is conveyed
to the mouth, so much are the actions of the muscles of the
tongue, pharynx, &c. impeded by impaired action and perpetual
agitation, that the food is with difficulty retained in the mouth
until masticated; and then as difficultly swallowed. Now also,
from the same cause, another very unpleasant circumstance oc-
curs: the saliva fails of being directed to the back part of the
fauces, and hence is continually draining from the mouth, mixed
with the particles of food, which he is no longer able to clear from
the inside of the mouth.
As the debility increases and the influence of the will over the
muscles fades away, the tremulours agitation becomes more vehe-
ment. It now seldom leaves him for a moment; but even when
exhausted (p. 9) nature seizes a small portion of sleep, the motion
Medical Classics
970
becomes so violent as not only to shake the bed-hangings, but
even the floor and sashes of the room. The chin is now almost
immovably bent down upon the sternum. The slops with
which he is attempted to be fed, with the saliva, are continually
trickling from the mouth. The power of articulation is lost.
The urine and faeces are passed involuntarily; and at the last,
constant sleepiness, with slight delirium, and other marks of
extreme exhaustion, announce the wished-for release.
case 1
Almost every circumstance noted in the preceding descrip-
tion, was observed in a case which occurred several years back,
and which, from the particular symptoms which manifested
themselves in its progress; from the little knowledge of its nature,
acknowledged to be possessed by the physician who attended;
and from the mode of its termination; excited an eager wish to
acquire some further knowledge of its nature and cause.
(p. 10) The subject of this case was a man rather more than
fifty years of age, who had industriously followed the business
of a gardener, leading a life of remarkable temperance and sobri-
ety. The commencement of the malady was first manifested by
a slight trembling of the left hand and arm, a circumstance which
he was disposed to attribute to his having been engaged for sev-
eral days in a kind of employment requiring considerable exer-
tion of that limb. Although repeatedly questioned, he could
recollect no other circumstance which he could consider as having
been likely to have occasioned his malady. He had not suffered
much from Rheumatism, or been subject to pains of the head,
or had ever experienced any sudden seizure which could be re-
ferred to apoplexy or hemiplegia. In this case, every circum-
stance occurred which has been mentioned in the preceding
history.
CASE 11
The subject of the case which was next noticed was casually
met with in the street. It was a man sixty-two years of age;
the (p. 11) greater part of whose life had been spent as an at-
tendant at a magistrate’s office. He had suffered from the dis-
Shaking Palsy 971
ease about eight or ten years. All the extremities were consid-
erably agitated, the speech was very much interrupted, and the
body much bowed and shaken. He walked almost entirely on
the fore part of his feet, and would have fallen every step if
he had not been supported by his stick. He described the dis-
ease as having come on very gradually, and as being, according
to his full assurance, the consequence of considerable irregular-
ities in his mode of living, and particularly of indulgence in spir-
ituous liquors. He was the inmate of a poor-house of a distant
parish, and being fully assured of the incurable nature of his
complaint, declined making any attempts for relief.
CASE III
The next case was also noticed casually in the street. The
subject of it was a man of about sixty-five years of age, of a re-
markable athletic frame. The agitation of the limbs, and indeed
of the head and of the whole body, was too vehement to allow it
(p. 12) to be designated as trembling. He was entirely unable
to walk; the body being so bowed, and the head thrown so for-
ward, as to oblige him to go on a continued run, and to employ
his stick every five or six steps to force him more into the up-
right posture, by projecting the point of it with great force
against the pavement. He stated, that he had been a sailor, and
attributed his complaints to having been for several months con-
fined in a Spanish prison, where he had, during the whole period
of his confinement, lain upon the bare damp earth. The disease
had here continued so long, and made such a progress, as to af-
ford little or no prospect of relief. He besides was a poor men-
dicant, requiring as well as the means of medical experiment,
those collateral aids which he could only obtain in a hospital.
He was therefore recommended to make trial if any relief could,
in that mode, be yielded him. The poor man, however, appeared
to be by no means disposed to make the experiment.
(p. 13) CASE IV
The next case which presented itself was that of a gentleman
about fifty-five years, who had first experienced the trembling
of the arms about five years before. His application was on ac-
Medical Classics
97 2
count of a considerable degree of inflammation over the lower
ribs on the left side, which terminated in the formation of matter
beneath the fascia. About a pint was removed on making the
necessary opening; and a considerable quantity discharged daily
for two or three weeks. On his recovery from this, no change
appeared to have taken place in his original complaint; and the
opportunity of learning its future progress was lost by his re-
moval to a distant part of the country.
CASE V
In another case, the particulars of which could not be obtained,
and the gentleman, the lamented subject of which was only seen
at a distance, one of the characteristic symptoms of this malady,
the inability for motion, except in a running pace, appeared to
exist in an extraordinary degree. It seemed (p. 14) to be neces-
sary that the gentleman should be supported by his attendant,
standing before him with a hand placed on each shoulder, until,
by gently swaying backward and forward, he had placed him-
self in equipoise; when, giving the word, he would start in a run-
ning pace, the attendant sliding from before him and running
forward, being ready to receive him and prevent his falling, after
his having run about twenty paces.
CASE vi
In a case which presented itself to observation since those
above-mentioned, every information as to the progress of the
malady was very readily obtained. The gentleman who was the
subject of it is seventy-two years of age. He has led a life of
temperance, and has never been exposed to any particular situa-
tion or circumstance which he can conceive likely to have oc-
casioned, or disposed to this complaint; which he rather seems to
regard as incidental upon his advanced age, than as an object of
medical attention. He however recollects, that about twenty
years ago, he was troubled (p. 15) with lumbago, which was
severe and lasted some time. About eleven or twelve, or per-
haps more, years ago, he first perceived weakness in the left hand
and arm, and soon after found the trembling had commenced. In
Shaking Palsy 973
about three years afterwards the right arm became affected in a
similar manner: and soon afterwards the convulsive motions
affected the whole body, and began to interrupt the speech. In
about three years from that time the legs became affected. Of
late years the action of the bowels had been very much retarded;
and at two or three different periods had, with great difficulty,
been made to yield to the action of very strong cathartics. But
within the last twelve months this difficulty has not been so great;
perhaps owing to an increased secretion of mucus, which en-
velopes the passing faeces, and which precedes and follows their
discharge in considerable quantity.
About a year since, on waking in the night, he found that he
had nearly lost the use of the right side, and that the face was
much drawn to the left side. His medical (p. 1 6) attendant saw
him the following day, when he found him languid, with a small
and quick pulse, and without pain in the head or disposition to
sleep. Nothing more therefore was done than to promote the
action of the bowels, and apply a blister to the back of the
neck, and in about a fortnight the limbs had entirely recovered
from their palsied state. During the time of their having re-
mained in this state, neither the arm nor the leg of the paralytic
side was in the least affected with the tremulous agitation; but as
their paralysed state was removed, the shaking returned.
At present he is almost constantly troubled with the agitation,
which he describes as generally commencing in a slight degree,
and gradually increasing, until it arises to such a height as to
shake the room; when, by a sudden and somewhat violent change
of posture, he is almost always able to stop it. But very soon
afterwards it will commence in some other limb, in a small de-
gree, and gradually increase in violence, but he does not remem-
ber the thus checking of it, to have been followed by any in-
jurious (p. 17) effect. When the agitation had not been thus
interrupted, he stated, that it gradually extended through all the
limbs, and at last affected the whole trunk. To illustrate his
observation as to the power of suspending the motion by a sud-
den change of posture, he, being then just come in from a walk,
with every limb shaking, threw himself rather violently into a
Medical Classics
974
chair, and said, “Now I am as well as ever I was in my life.”
The shaking completely stopped; but returned within two min-
utes’ time.
He now possessed but little power in giving a required direc-
tion to the motions of any part. He was scarcely able to feed
himself. He had written hardly intelligibly for the last three
years; and at present could not write at all. His attendants
observed, that of late the trembling would sometimes begin in
his sleep, and increase until it awakened him: when he always was
in a state of agitation and alarm.
On being asked if he walked under much apprehension of fall-
ing forwards? he said he suffered much from it; and replied in
the (p. 1 8 ) affirmative to the question, whether he experienced
any difficulty in restraining himself from getting into a running
pace? It being asked, if whilst walking he felt much apprehen-
sion from the difficulty of raising his feet, if he saw a rising pebble
in his path? he avowed, in a strong manner, his alarm on such
occasion; and it was observed by his wife, that she believed, that
in walking across the room he would consider as a difficulty the
having to step over a pin.
The preceding cases appear to belong to the same species: dif-
fering from each other, perhaps, only in the length of time which
the disease had existed, and the stage at which it had arrived.
(p. 19) Chap. II. Pathognomonic Symptoms Examined —
Tremor Coactus — Scelotyrbe Festinans
It has been seen in the preceding history of the disease, and in
the accompanying cases, that certain affections, the tremulous
agitation, and the almost invincible propensity to run, when
wishing only to walk, each of which has been considered by
nosologists as distinct diseases, appear to be pathognomonic
symptoms of this malady. To determine in which of these
points of view these affections ought to be regarded, an examina-
tion into their nature, and an inquiry into the opinions of pre-
ceding writers respecting them, seem necessary to be attempted.
Shaking Palsy 975
I. Involuntary tremulous motion , with lessened voluntary muscular
power, in parts, not in action, and even supported
It is necessary that the peculiar nature of this tremulous mo-
tion should be ascertained, as well for the sake of giving to it its
proper (p. 20) designation, as for assisting in forming probable
conjectures, as to the nature of the malady, which it helps to
characterise. Tremors were distinguished by Juncker into Ac-
tive, those proceeding from sudden affection of the minds, as
terror, anger, &c. and Passive, dependant on debilitating
causes, such as advanced age, palsy, &c.*. But a much more
satisfactory and useful distinction is made by Sylvius de la Boe
into those tremors which are produced by attempts at volun-
tary motion, and those which occur whilst the body is at restj.
Sauvages distinguishes the latter of these species {Tremor (p. 21)
Coactus) by observing, that the tremulous parts leap, and as it
were vibrate, even when supported: whilst every other tremor,
he observes, ceases, when the voluntary exertion for moving the
limb stops, or the part is supported, but returns when we will the
limb to move; whence, he says, tremor is distinguished from
every other kind of spasml.
A small degree of attention will be sufficient to perceive, that
Sauvages, by this just distinction, actually separates this kind
of tremulous motion, and which is the kind peculiar to this dis-
* Junckeri conspect, de tremore.
t Sect. V. Ubi autem solito paudores deferunter ad eadem organa spiritus animales,
imperfectae ac imbcallae observantur fieri eadem funcriones, in motu tremulo et infirmo,
nec diu durante, in visu debili, ac mox defatigato, &c.
Sect. XIX. Inaequaliter, inordinate, ac praeter contraque voluntatem moventur
spiritus animales per nervos ad partes mobiles, in motu convulsivo, ac tremore, quassuve
membrorum coacto.
Distinguendus namque his tremor quiescente licet ac decumbente corpore molustus
a motu tremulo, de quo dictum. Sect. V. Quique quiescente corpore cessat, codemque
iterum moto rcpetit.
Sect. XXV. Coactus tremor debetur animalibus spiritibus inordinate ac continuo,
cum aliquo impetu ad trementium membrorum musculos per nervos propulsis: sive fuerit
is universalis, sive particularis, sive corpus fuerit ad hue robustum sive debile, Sylvii de la
Boe. Prax. lib. i. cap. xlii.
t Xosolog. Methodic. Auctore Fr. Boissier de Sauvages, Tomi. II. Partis ii. p. 54.
Medical Classics
976
ease, from the Genus Tremor. In doing this he is fully war-
ranted by the observations of Galen on the same subject, as
noticed by Van Swieten*. “Binas has tremoris species! Galenus
subtiliter (p. 22) distinxit, atque etiam diversis nomimbus in-
signivit, tremor enim ( rponos ) facultatis corpus moventis et
vehentis infirmitate oboritur. Quippe nemo, qui artus movere
non instituerit tremet. Palpitantes autem partes, etiam in
quiete fuerint, etiamsi nullum illis motum induxeris palpitant.
Ideo primam ( posteriorem ) modo descriptam tremoris speciem,
quando quiescenti homini involuntariis illis et alternis motibus
agitantur membra, palpitationem (ttoXhov) dixit, posteriorem
( -primam ) vero, quae non fit nisi homo conetur partes quasdam
movere tremorem vocavit.”
Under this authority the term palpitation may be employed
to mark those morbid motions which chiefly characterise this
disease, notwithstanding that this term has been anticipated by
Sauvages, as characteristic of another species of tremorj. The
(p. 23) separation of palpitation of the limbs {Palmos of Galen,
tremor Coactus of de la Boe) from tremor, is the more necessary
to be insisted on, since the distinction may assist in leading to a
knowledge of the seat of the disease. It is also necessary to
bear in mind, that this affection is distinguishable from tremor,
by the agitation, in the former, occurring whilst the affected part
is supported and unemployed, and being even checked by the
adoption of voluntary motion: whilst in the latter, the tremor is
induced immediately on bringing the parts into action. Thus
* Comment, in Herman. Boerhaav. Aphorismos. Tom. ii. p. x8i.
t De tremore. Cap. 3 and 4. Chart, Tom. vii. p. 10 o, 201.
t Sect, XVI. Tremor palpitans , Preysinger classis morborum. Palmos Galeni.
In tremoribus vulgaribus, aequalibus temporum intervallis, non musculus, sed artus
ipsemet alternation attollitur aut deprimitur, aut in oppositas partes it atque redit per
minima tamen spatiola; in palpi tatione vero sine ullo ordine musculi unius lacertus subito
subsilit, nec regulariter continuoque movetur, sed nunc semel aut bis, nunc minime intra
idem tempus subsilit; an causa irritans in sensorio communi, an in musculo ipse palpi tante
Quaerenda sit, ignoramus. Nosologiac Methodicae> Vol. I. p. 559 1768.
But the adoption which Sauvages has made of this term, will not be regarded as an
absolute prohibition from the employment of it here; since the tremor palpitans of Sau-
vages should be considered rather as a palpitation of the muscles, whilst the motion which
is so prominent a symptom in this disease, may be considered as a palpitation of the limbs.
Shaking Palsy 977
an artist, afflicted with the malady here treated of, whilst his
hand and arm is palpitating strongly, will seize his pencil, and the
motions will be suspended, allowing (p. 24) him to use it for a
short period; but in tremor, if the hand be quite free from the
affection, should the pen or pencil be taken up, the trembling
immediately commences.
II. A propensity to bend the trunk forwards , and to pass from a
walking to a running pace
This affection, which observation seems to authorise the being
considered as a symptom peculiar to this disease, has been men-
tioned by few nosologists: it appears to have been first noticed
by Gaubius, who says, “Cases occur in which the muscles duly
excited into the action by the impulse of the will, do then, with
an unbidden agility, and with an impetus not to be repressed,
accelerate their motion, and run before the unwilling mind. It
is a frequent fault of the muscles belonging to speech, nor yet of
these alone: I have seen one, who was able to run', but not to
walk*.”
(p. 25) Sauvages, referring to this symptom, says, another
disease which has been very rarely seen by authors, appears to
be referable to the same genus (Scelotyrbe, of which he makes
Chorea sancti viti the first species); which, he says, “I think can-
not be more fitly named than hastening or hurrying Scelotyrbe
( Scelotyrbem festinantem , seu festiniam).”
Scelotyrbe festinans , he says, is a peculiar species of scelotyrbe,
in which the patients, whilst wishing to walk in the ordinary
mode, are forced to run, which has been seen by Carguet and by
the illustrious Gaubius; a similar affection of the speech, when
the tongue thus outruns the mind, is termed volubility. Mons.
de Sauvages attributes this complaint to a want of flexibility in
the muscular fibres. Hence, he supposes, that the patients make
* Estct ubi musculi, recte quidem ad voluntatis nutum in actum concitad, injussa dein
agilitate atque impetu non reprimendo motus suos accelerant, mentemque invitam prae-
currunt. Virium loquelae musculis frequens, nec his solis tamen proprium: vidid enim,
qui currere, non gradi, poterat*.
Institution, Patholog. Medicinal. Auctore. H. D. Gaubio. 751.
Medical Classics
978
shorter steps, and strive with a more than common exertion or
impetus to overcome the resistance; walking with a quick and
hastened step, as if hurried along against their will. Chorea
Viti 3 he (p. 26) says, attacks the youth of both sexes, but this dis-
ease only those advanced in years; and adds, that it has hitherto
happened to him to have seen only two of these cases; and that
he has nothing to offer respecting them, either in theory or
practice*.
(p. 27) Having made the necessary inquiries respecting these
two affections, Tremor coactum of Sylvius de la Boe and of Sau-
vages, and Scelotyrbe festinans of the latter nosologist, which ap-
pear to be characteristic symptoms of this disease, it becomes
necessary, in the next place, to endeavour to distinguish this
disease from others which may bear a resemblance to it in some
particular respects.
Chap. III. Shaking Palsy Distinguished From Other Dis-
eases With Which It May Be Confounded
Treating of a disease resulting from an assemblage of symp-
toms, some of which do not appear to have yet engaged the gen-
eral notice of the profession, particular care is required whilst
endeavouring to mark its diagnostic characters. It is sufficient,
*Ad idem genus niorbi altera species rarissima ab auctoribus praeterivisa referenda
videtur, quam non aptius nominari posse putem quam scelotyrbem festinantem, seu
festiniam.
Sect. II. Scelotyrbe festinans; est peculiaris scelotyrbes spedes in qua aegri soli to more
dum gradi volunt currere cogun tur, quod videre est apud D. Carquet, et observavit Leydae
illustr. Gaubius. Patkohg. instit . 751, et in loquela haec tolubilitas didtur qua lingua
praecurrit men turn. Video actu mulierem sexagenariam hoc aiFectam morbo siedtati
nervorum tribuendo; laborat enim rheumatismo sicco, seu ab acrimonia sanguinis, dolores
nocte a calore recrudescunt, a thermis non sublevantur; ei praescripsi phebotomiam, et
praemissis jusculis ex lactuca, endivia, et collo arieds, lene cathardcum, inde vero lacri-
dnia.
Est affinitas cum scelotyrbe, chorea vid, deest flexi bilitas in fibris musculorum; unde
motus breves edunt, et conatu seu impetu solito majori, cum resistendam illam superare
nituntur, velut invid festinant, ac praedpid seu conritato passu gradiuntur. Chorea vid
pueros, puellasve impuberes aggreditur; fesdnia vero senes, et duos tantum hactenus
observare mi hi condgit. Quam multos autem vid emus morbos, pauassimosque obser-
vamus. De theoria et praxi nihil habeo quod dicam; etenim sola experienta praxim cu-
jusvis morbi determinat, et ex hac pro feliri vel infausto successu theoria dein eiidenda
est. Nosolog \ Methodic . Auctore, Fr. Boissier de Sauvages. Tomi, ii. Part ii. p. 108.
Shaking Palsy 979
in general, to point out the characteristic differences which are
observable between diseases in some respects resembling each
other. But in this case more is required: it is necessary to show
that it is a disease (p. 28) which does not accord with any which
are marked in the systematic arrangements of nosologists; and
that the name by which it is here distinguished has been hitherto
vaguely applied to diseases very different from each other, as
well as from that to which it is now appropriated.
Palsy, either consequent to compression of the brain, or de-
pendent on partial exhaustion of the energy of that organ, may,
when the palsied limbs become affected with tremulous motions,
be confounded with this disease. In those cases the abolition or
diminution of voluntary muscular action takes place suddenly,
the sense of feeling being sometimes also impaired. But in this
disease, the diminution of the influence of the will on the muscles
comes on with extreme slowness, is always accompanied, and
even preceded, by agitations of the affected parts, and never by
a lessened sense of feeling. The dictates of the will are even,
in the last stages of the disease, conveyed to the muscles; and the
muscles act on this impulse, but their actions are perverted.
Anomalous cases of convulsive affections (p. 29) have been
designated by the term Shaking Palsy: a term which appears to
be improperly applied to these cases, independent of. the want of
accordance between them and that disease which has been here
denominated Shaking Palsy. Dr. Kirkland, in his commentary
on Apoplectic and Paralytic Affections, &c. cites the following
case, related by Dr. Charlton, as belonging, he says to the class
of Shaking Palsies. “Mary Ford, of a sanguineous and robust
constitution, had an involuntary motion of her right arm, oc-
casioned by a fright, which first brought on convulsion fits, and
most excruciating pain in the stomach, which vanished on a sud-
den, and her right arm was instantaneously flung into an invol-
untary and perpetual motion, like the swing of a pendulum,
raising the hand, at every vibration higher than her head; but if
by any means whatever it was stopped; the pain in her stomach
came on again, and convulsion fits were the certain consequence,
which went off when the vibration of her hand returned.”
980 Medical Classics
Another case, which the Doctor designates as “A Shaking
Palsy,” apparently from worms, he describes thus, “A poor boy,
about (p. 30) twelve or thirteen years of age, was seized with a
Shaking Palsy. His legs became useless, and together with his
head and hands, were in continual agitation; after many weeks
trial of various remedies, my assistance was desired.
“His bowels being cleared, I ordered him a grain of Opium a
day in the gum pill; and in three or four days the shaking had
nearly left him.” By pursuing this plan, the medicine proving
a vermifuge, he could soon walk, and was restored to perfect
health.
Whether these cases should be classed under Shaking Palsy or
not, is necessary to be here determined; since, if they are properly
ranked, the cases which have been described in the preceding
pages, differ so much from them as certainly to oppose their
being classed together; and the disease, which is the subject of
these pages, cannot be considered as the same with Shaking
Palsy, as characterised by those cases.
The term Shaking Palsy is evidently inapplicable to the first
of these cases, which (p. 31) appears to have belonged more prop-
erly to the genus Convulsio, of Cullen, or to Hieranosos of Lin-
naeus and Vogel.*
The latter appears to be referable to that class of proteal forms
of disease, generated by a disordered state of primae viae, sym-
pathetically (p. 32) affecting the nervous influence in a distant
part of the body.
* Corporis agitatio continua, indolens, convulsiva, cum sensibiiitate. — Linn.
Agitatio corporis vel artuum convulsiva continua, chronica, cum integritate sensuum. —
Vogel.
This genus is resolved by Cullen into that of Convulsio. Synops. Nosol. 1803.
Dr. Macbride has given a very interesting and illustrative case of this disease.
‘THeranasos, or Morbus Sacer, so called, as being vulgarly supposed to arise from
witchcraft, or some extraordinary celestial influence, is a distinct genus of disease, though
a very uncommon one; the author once had an opportunity of seeing a case. The patient
was a lad about seventeen, who at that time had laboured under this extraordinary disease
for more than twelve years. His body was so distorted, and the legs and arms so twisted
round it, by the continued convulsive working, that no words can give an adequate idea
of the oddity of his figure; the agitation of the muscles was perpetual; but in general he
did not complain of pain nor sickness; and had his sense perfectly, insomuch that he used
to assist his mother, who kept a little school, in teaching children to read." A methodical
Introduction to the Theory and Practice of Physic. By David Macbride, M.D. p. 559.
Shaking Palsy 981
Unless attention is paid to one circumstance, this disease will
be confounded with those species of passive tremblings to which
the term Shaking Palsies has frequently been applied. These
are, tremor temulentus, the trembling consequent to indulgence
in the drinking of spirituous liquors; that which proceeds from
the immoderate employment of tea and coffee; that which ap-
pears to be dependent on advanced age; and all those tremblings
which proceed from the various circumstances which induce a
diminution of power in the nervous system. But by attending
to that circumstance alone, which has been already noted as
characteristic of mere tremor, the distinction will readily be
made. If the trembling limb be supported, and none of its
muscles be called into action, the trembling will cease. In the
real Shaking Palsy the reverse of this takes place, the agitation
continues in full force whilst the limb is at rest and unemployed;
and even is sometimes diminished by calling the muscles into
employment.
(p. 33) Chap. IV. Proximate Cause — Remote Causes —
Illustrative Cases
Before making the attempt to point out the nature and cause
of this disease, it is necessary to plead, that it is made under very
unfavourable circumstances. Unaided by previous inquiries
immediately directed to this disease, and not having had the
advantage, in a single case, of that light which anatomical ex-
amination yields, opinions and not facts can only be offered.
Conjecture founded on analogy, and an attentive consideration
of the peculiar symptoms of the disease, have been the only
guides that could be obtained for this research, the result of
which is, as it ought to be, offered with hesitation.
SUPPOSED PROXIMATE CAUSE
(A diseased state of the medulla spinalis, in that part which is
contained in the canal, formed by the superior cervical (p. 34)
vertebrae, and extending, as the disease proceeds, to the medulla
oblongata)
By the nature of the symptoms we are taught, that the dis-
ease depends on some irregularity in the direction of the nervous
Medical Classics
982
influence; by the wide range of parts which are affected, that the
injury is rather in the source of this influence than merely in the
nerves of the parts; by the situation of the parts whose actions
are impaired, and the order in which they become affected, that
the proximate cause of the disease is in the superior part of the
medulla spinalis; and by the absence of any injury to the senses
and to the intellect, that the morbid state does not extend to the
encephalon.
Uncertainty existing as to the nature of the proximate cause
of this disease, its remote causes must necessarily be referred to
with indecision. Assuming however the state just mentioned
as the proximate cause, it may be concluded that this may be the
result of injuries of the medulla itself, or of the theca helping to
form the canal in which it is inclosed.
(p. 35) The great degree of mobility in that portion of the spine
which is formed by the superior cervical vertebrae, must render it,
and the contained parts, liable to injury from sudden distortions.
Hence therefore may proceed inflammation of quicker or of
slower progress, disease of the vertebrae, derangement of struc-
ture in the medulla, or in its membranes, thickening or even
ulceration of the theca, effusion of fluids, &c.
But in no case which has been noticed, has the patient rec-
ollected receiving any injury of this kind, or any fixed pain in
early life in these parts, which might have led to the opinion that
the foundation for this malady has been thus laid. On the sub-
ject indeed of remote causes, no satisfactory accounts has yet
been obtained from any of the sufferers. Whilst one has attrib-
uted this affliction to indulgence in spirituous liquors, and
another to long lying on the damp ground; the others have been
unable to suggest any circumstance whatever, which, in their
opinion, could be considered as having given origin, or disposed,
to the calamity under which they suffered.
(p. 36) Cases illustrative of the nature and cause of this
malady are very rare. In the following case symptoms very
similar are observable, so far as affecting the lower extremities.
That the medulla spinalis was here affected, and in its lower
part, is not to be doubted: but this, unfortunately, was never
Shaking Palsy 983
ascertained by examination. It must be however remarked,
that this case differed from those which have been given of this
disease, in the suddenness with which the symptoms appeared.
A. B. aged twenty-six years, during a course of mercury for a
venereal affection, was exposed to severely inclement weather,
for several hours, and the next morning, complained of extreme
pain in the back, and of total inability to employ voluntarily
the muscles of the lower extremities, which were continually
agitated with severe convulsive motions. The physician who
attended him employed those means which seemed best calcu-
lated to relieve him; but with no beneficial effect. The lower
extremities were perpetually agitated with strong palpitatory
motions, and, frequently, (p. 37) three or four times in a minute,
suddenly raised with great vehemence two or three feet from the
ground, either in a forward or oblique direction, striking one
limb against the other, or against the chairs, tables, or any sub-
stance which stood in the way. To check these inordinate mo-
tions, no means were in the least effectual, except striking the
thighs forcibly during the more violent convulsions. No ad-
vantage was derived from all the means which were employed
during upwards of twelve months. Full ten years after this pe-
riod, the unhappy subject of this malady was casually met in the
street, shifting himself along, seated in a chair; the convulsive
motions having ceased, and the limbs having become totally in-
ert, and insensible to any impulse of the will.
It must be acknowledged, that in the well-known cases, de-
scribed by Mr. Potts, of that kind of Palsy of the lower limbs
which is frequently found to accompany a curvature of the spine,
and in which a carious state of the vertebrae is found to exist,
no instructive analogy is discoverable; slight convulsive motions
may indeed (p. 38) happen in the disease proceeding from cur-
vature of the spine; but palpitating motions of the limbs, such
as belong to the disease here described, do not appear to have
been hitherto noticed.
Whilst striving to determine the nature and.origin of this dis-
ease, it becomes necessary to give the following particulars of an
interesting case of Palsy occasioned by a fall, attended with un-
Medical Classics
984
common symptoms, related by D. Maty, in the third volume- of
the Medical Observations and Inquiries. The subject of this
case, the Count de Lordat, had the misfortune to be overturned
from a pretty high and steep bank. His head pitched against the
top of the coach, and was bent from left to right; his left shoulder,
arm, and especially his hand, were considerably bruised. At
first he felt a good deal of pain along the left side of his neck, but
neither then, nor at any other time, had he any faintings, vom-
itings, or giddiness. — On the sixth day he was let blood, on ac-
count of the pain in his shoulder and the contusion of his hand,
which were then the only symptoms he (p. 39) complained of,
and of which he soon found himself relieved. — Towards the be-
ginning of the following winter, he began to find a small imped-
iment in uttering some words , and his left arm appeared weaker.
In the following spring, having suffered considerably from the
severities of the winter campaign, he found the difficulty in
speaking , and in mooing his left arm , considerably increased . —
On employing the thermal waters of Bourbonne, his speech be-
come freer, but, on his return to Paris, the Palsy was increased,
and the arm somewhat wasted. — In the beginning of the next
spring he went to Balaruc; when he became affected with in-
voluntary convulsive motions all over the body. The left arm with-
ered more and more, a spitting began , and now it was with diffi-
culty that he uttered a few words. Frictions and sinapisms were
successively tried, and an issue, made by a caustic, was kept
open for some time without any effect; but no mention is made
of what part the issue was established in.
Soon after this, and three years and a half after the fall,
Doctor Maty first saw the patient, and gives the following de-
scription of (p. 40) his situation. “A more melancholy object
I never beheld. The patient, naturally a handsome, middle-
sized, sanguine man, of a cheerful disposition, and an active
mind, appeared much emaciated, stooping, and dejected. He
still walked alone with a cane, from one roo?n to the other , but with
great difficulty, and in a tottering manner ; his left hand and arm
were much reduced, and would hardly perform any motion;
the right was somewhat benumbed, and he could scarcely lift it up to
Shaking Palsy 985
his head ; his saliva -was continually trickling out of his mouth ,
and he had neither the power of retaining it, nor of spitting it out
freely. What words he still could utter were monosyllables, and
these came out, after much struggle, in a violent expiration, and
with such a low voice and indistinct articulation, as hardly to be
understood but by those who were constantly with him. He
fetched his breath rather hard; his pulse was low, but neither
accelerated nor intermitting. He took very little nourishment,
could chew and swallow no solids, and even found great pain in
getting down liquids. Milk was almost his only food; his body
was rather loose, his urine (p. 41) natural, his sleep good, his
senses, and the powers of his mind, unimpaired; he was attentive
to, and sensible of every thing which was said in conversation,
and shewed himself very desirous of joining in it; but was con-
tinually checked by the impediment in his speech, and the diffi-
culty which his hearers were put to. Happily for him he was
able to read, and as capable as ever of writing, as he shewed me,
by putting into my hands an account of his present situation,
drawn up by himself: and I am informed that he spent his time
to the very last, in writing upon some of the most abstruse
subjects.” ,
This gentleman died about four years after the accident,
when the body was examined by Dr. Bellett and Mons. Sorbier,
who made the following report:
“We first examined the muscles of the tongue, which were
found extenuated and of a loose texture. We observed no signs
of compression in the lingual and brachial nerves, as high as
their exit from the basis of the cranium and the vertebrae of
the neck; (p. 42) but they appeared to us more compact than
they commonly are; being nearly tendinous. The dura mater
was in a sound state, but the pia mater was full of blood and
lymph; on it several hydatids, and towards the falx some marks
of suppuration were observed. The ventricles were filled with
water, and the plexus choroides were considerably enlarged, and
stuffed with grumoun blood. The cortical surface of the brain
appeared much browner than usual, but neither the medullary
part nor cerebellum were impaired. We chiefly took notice of
Medical Classics
986
the Medulla Oblongata, this was greatly enlarged, surpassing the
usual size by more than one third. It was likewise more com-
pact. The membranes, which, in their continuation, inclose the
spinal marrow, were so tough that we found great difficulty in
cutting through them, and we observed this to be the cause of
the tendinous texture of the cervical nerves. The marrow itself
had acquired such solidity as to elude the pressure of our fingers,
it resisted as a callous body, and could not be bruised. This
hardness was observed all along the vertebrae of the neck, but
lessened by degrees, and (p. 43) was not near so considerable in
the vertebrae of the thorax. Though the patient was but nine
and thirty years old, the cartilages of the sternum were ossified,
and required as much labour to cut them asunder as the ribs;
like these they were spungy, but somewhat whiter. The lungs
and heart were sound. At the bottom of the stomach appeared
an inflammation, which increased as it extended to the intestines.
The ileum looked of that dark and livid hue, which is observed in
membranous parts tending to mortification. The colon was not
above an inch in diameter, the rectum was smaller stall, but both
appeared sound. — From these appearances, we were at no loss
to fix the cause of this gradual palsy in the alteration of the me-
dulla spinalis and oblongata.”
Dr. Bellett offers the following explanation of these changes.
“I conceive, that, by this accident, the head being violently
bent to the right, the nervous membranes on the left were ex-
cessively stretched and irritated; that this cause extended by
degrees to the spinal marrow, which being (p. 44) thereby com-
pressed, brought on the paralytic symptoms, not only of the
left arm, but at last in some measure also of the right. This
induration seems to have been occasioned by the constant afflux
of the nutritive juices, which were stopt at that place, and de-
prived of their most liquid parts; the grosser ones being unable
to spread in the bony cavity, by which they were confined,
could only acquire a greater solidity, and change a soft body
into a hard and nearly osseous mass. This likewise accounts
for the increase of the medulla oblongata, which being loaded
with more juices than it could send off, swelled in the same
Shaking Palsy 987
manner as the branches of trees, which will grow of a monstrous
size, when the sap that runs into them is stopt in its progress.
The medulla oblongata not growing so hard as the spinalis, was
doubtless owing to its not being confined in an osseous theca,
but surrounded with soft parts, which allowed it room to spread.
The obstruction from the bulk of this substance must have af-
fected the brain, and probably induced the thickening of the pia
mater, the hydatids, and the beginning of suppuration, whereas
the dura (p. 45) mater being of a harder texture, was not in-
jured.*”
In some of the symptoms which appeared in this case, an
agreement is observable between it and those cases which are
mentioned in the beginning of these pages. The weakened state
of both arms; the power first lessening in one arm, and then in a
similar manner in the other arm; the affection of the speech; the
difficulty in chewing and in swallowing; as well as of retaining,
or freely discharging, the spittle; the convulsive motions of the
body; and the unimpaired state of the intellects; constitute such
a degree of accordance as, although it may not mark an identity
of disease, serves at least to show that nearly the same parts were
the seat of the disease, in both instances. Thus we attain some-
thing like confirmation of the supposed proximate cause, and of
one of the assumed occasional causes.
Whilst conjecturing as to the cause of this disease, the follow-
ing collected observations (p. 46) on the effects of injury to the
medulla spinalis, by Sir Everard Home, become particularly de-
serving of attention. It thence appears, that none of the char-
acteristic symptoms of this malady are produced by compres-
sion, laceration, or complete division of the medulla spinalis.
“Pressure upon the medulla spinalis of the neck, by coagulated
blood, produced paralytic affections of the arm and legs; all the
functions of the internal organs were carried on for thirty-five
days, but the urine and stools passed involuntarily.!
* Medical Observations and Inquiries, VoL III. p. 257.
t A coagulum of blood, the thickness of a crown-piece, was found lying upon the ex-
ternal surface of the dura-matral covering of the medulla spinalis, extending from the
fourth vertebra colli to the second vertebra dorsi. The medulla spinalis itself was un-
injured.
Medical Classics
988
“Blood extravasated in the central part of the medulla, in the
neck, was attended with paralytic affection of the legs, but not
of the arms*.
(p. 47) “In a case where the substance of the medulla was
lacerated in the neck, there was a paralysis in all the parts below
the laceration, the lining of the oesophagus was so sensible,
that solids could not be swallowed, on account of the pain they
occasioned-f
“When the medulla of the back was completely divided, there
was momentary loss of sight, loss of memory for fifteen minutes,
and permanent insensibility in all the lower parts of the body.
The skin above the division of the spinal marrow perspired, that
below did not. The wounded spinal marrow appeared to be ex-
tremely sensible!.” Philosophical ‘Transactions 1816, p. 485.
In two of the cases already noticed, symptoms of rheumatism
had previously existed; and in Case IV. the right arm, in which
the palpitation began, was said to (p. 48) have been very vio-
lently affected with rheumatic pain to the finger ends. The
consideration of this case, in which the palpitation had been
preceded, at a considerable distance of time, by this painful
affection of the arm, led to the supposition that this latter cir-
cumstance might be the cause of the palpitations, and the other
subsequent symptoms of this disease. This supposition natu-
rally occasioned the attention to be eagerly fixed on the following
case; and of course influenced the mode of treatment which was
adopted.
A. B. subject to rheumatic affection of the deltoid muscle, had
felt the usual inconveniences from it for two or three days; but
at night found the pain had extended down the arm, along the
inside of the fore-arm, and on the sides of the fingers, in which a
continual tingling was felt. The pain, without being extremely
* The sixth and seventh vertebra colli were dislocated, the medulla spinalis, externallyj
was uninjured; but in the centre of its substance, just at that part, there was a coagulam
of blood nearly two inches in length,
f The seventh vertebra colli was fractured, and the medulla spinalis passing through it,
was lacerated and compressed,
} The spinal marrow, within the canal of the sixth vertebra dorsi, was completely
destroyed by a musket ball. The person lived four days.
Shaking Palsy 989
intense, was such as effectually to prevent sleep: and seemed to
follow the course of the brachial nerve. Whilst ascertaining the
propriety of this conclusion, the pain was found to ramify, as it
were, on the fore and back part of the (p. 49) chest; and was
slightly augmented by drawing a deep breath.
These circumstances suggested the probability of slight in-
flammation, or increased determination to the origin of the
nerves of these parts, and to the neighbouring medulla. On
this ground, blood was taken from the back part of the neck, by
cupping; hot fomentations were applied for about the space of
an hour, when the upper part of the back of the neck was
covered with a blister, perspiration was freely induced by two or
three small doses of antimonials, and the following morning the
bowels were evacuated by an appropriate dose of calomel. On
the following day the pains were much diminished, and in the
course of four or five days were quite removed. The arm and
hand felt now more than ordinarily heavy, and were evidently
much weakened: aching, and feeling extremely wearied after the
least exertion. The strength of the arm was not completely re-
covered at the end of more than twelvemonths; and, after more
than twice that time, exertion would excite the feeling of painful
weariness, but no palpitation (p. 50) or other unpleasant symp-
tom has occurred during the five or six years which have since
passed.
The commencement, progress, and termination of this attack;
with the success attending the mode of treatment, and the symp-
toms which followed, seem to lead to the conjecture, that the
proximate cause of the disease, in this case, existed in the me-
dulla spinalis, and that it might, if neglected, have gradually re-
solved itself into that disease which is the object of our present
inquiry.
Some few months after the occurrence of the preceding case,
the writer of these lines was called to a female about forty jeans
°f age, complaining of great pain in both the arms, extending
from the shoulder to the finger ends. She stated, that she was
attacked in the same manner as is described in the preceding case,
about nine months before; that the complaint was consi ere as
Medical Classics
990
rheumatism, and was not benefited by any of the medicines
which had been employed; but that after three or four weeks
(p. 51) it gradually amended, leaving both the arms and hands in
a very weakened and trembling state. From this state they
were now somewhat recovered; but she was extremely anxious,
fearing that if the present attack should not be soon checked,
she might entirely lose the use of her hands and arms.
Instructed by the preceding case, similar means were here
recommended. Leeches, stimulating fomentations, and a blister,
which was made for sometime to yield a purulent discharge,
were applied over the cervical vertebrae; and in the course of a
very few days the pain was entirely removed. It is regretted
that no farther information, as to the progress of this case, could
be obtained.
On meeting with these two cases, it was thought that it might
not be improbable that attacks of this kind, considered at the
time merely as rheumatic affections, might lay the foundation
of this lamentable disease, which might manifest itself at some
distant period, when the circumstance in which it had originated,
had, perhaps, almost escaped (p. 52) the memory. Indeed when
it is considered that neither in the ordinary cases of Palsy of the
lower extremities, proceeding from diseased spine, nor in cases
of injured medulla from fractured vertebrae, any of the peculiar
symptoms of this disease are observable, we necessarily doubt
as to the probability of its being the direct effect of any sudden
injury. But taking all circumstances into due consideration,
particularly the very gradual manner in which the disease com-
mences, and proceeds in its attacks; as well as the inability to
ascribe its origin to any more obvious cause, we are led to seek
for it in some slow morbid change in the structure of the medulla,
or its investing membranes, or theca, occasioned by simple in-
flammation, or rheumatic or scrophulous affection.
It must be too obvious that the evidence adduced as to the
nature of the proximate and occasional causes of this disease,
is by no means conclusive. A reference to the test therefore
which will be yielded by an examination of some of the more
prominent symptoms, especially as to their agreement (p. 53)
Shaking Palsy 991
with the supposed proximate cause, is more particularly de-
manded. Satisfied as to the importance of this part of the pres-
ent undertaking, no apology is offered for the extent to which the
examination is carried on.
If the palpitation and the attendant weakness of the limbs,
&c. be considered as to the order in which the several parts are
attacked, it is believed, that some confirmation will be obtained
of the opinion which has been just offered, respecting the cause,
or at least the seat, of that change which may be considered as
the proximate cause of this disease.
One of the arms, in all the cases which have been here men-
tioned, has been the part in which these symptoms have been
first noticed; the legs, head, and trunk have then become grad-
ually affected, and lastly, the muscles of the mouth and fauces
have yielded to the morbid influence.
The arms, the parts first manifesting disordered action, of
course direct us, whilst (p. 54) searching for the cause of these
changes, to the brachial nerves. But finding the mischief ex-
tending to other parts, not supplied with these, but with other
nerves derived from nearly the same part of the medulla spina-
lis, we are of course led to consider that portion of the medulla
spinalis itself, from which these nerves are derived, as the part
in which those changes have taken place, which constitute the
proximate cause of this disease.
From the subsequent affection of the lower extremities, and
from the failure of power in the muscles of the trunk, such a
change in the substance of the medulla spinalis may be inferred,
as shall have considerably interrupted, and interfered with, the
extension of the nervous influence to those parts, whose nerves
are derived from any portion of the medulla below the part which
has undergone the diseased change.
The difficulty in supporting the trunk erect, as well as the
propensity to the adopting of a hurried pace, is also referable to
such a diminution of the nervous power in (p. 55) the extensor
muscles of the head and trunk, as prevents them from per-
forming the offices of maintaining the head and body in an erect
position.
Medical Classics
992
From the impediment to speech, the difficulty in mastication
and swallowing, the inability to retain, or freely to eject, the
Saliva, may with propriety be inferred an extension of the mor-
bid change upwards through the medulla spinalis to the medulla
oblongata, necessarily impairing the powers of the several nerves
derived from that portion into which the morbid change may
have reached. In the late occurrence of this set of symptoms,
and the extension upwards of the diseased state, a very close
agreement is observable between this disease and that which
has been already shown, proved fatal to the Count de Lordat.
But in this case, the disease doubtlessly became differently mod-
ified, and its symptoms considerably accelerated, in consequence
of the magnitude of the injury by which the disease was induced.
(p. 56) Chap. V. Considerations Respecting The Means
of Cure
The inquiries made in the preceding pages yield, it is to be
much regretted, but little more than evidence of inference;
nothing direct and satisfactory has been obtained. All that has
been ventured to assume here, has been that the disease depends
on a disordered state of that part of the medulla which is con-
tained in the cervical vertebrae. But of what nature that mor-
bid change is; and whether originating in the medulla itself, in
its membranes, or in the containing theca, is, at present, the
subject of doubt and conjecture. But although, at present,
uninformed as to the precise nature of the disease, still it ought
not be considered as one against which there exists no counter-
vailing remedy.
On the contrary, there appears to be sufficient reason for
hoping that some remedial process may ere long be discovered,
by which, at least, the progress of the disease may be (p. 57)
stopped. It seldom happens that the agitation extends beyond
the arms within the first two years; which period, therefore, if we
were disposed to divide the disease into stages, might be said to
comprise the first stage. In this period, it is very probable,
Shaking Palsy 993
that remedial means might be employed with success: and even,
if unfortunately deferred to a later period, they might then ar-
rest the farther progress of the disease, although the removing
of the effects already produced, might be hardly to be expected.
From a review of the changes which had taken place in the
case of Count de Lordat, it seems as if we were able to trace the
order and mode in which the morbid changes may proceed in
this disease. From any occasional cause, the thecal ligament,
the membranes, or the medulla itself, may pass into the state of
simple excitement or irritation, which may be gradually suc-
ceeded by such a local afflux and determination of blood into the
minute vessels, as may terminate in actual but slow inflamma-
tion. The result of this would be a thickening (p. 58) of the
theca, or membranes, and perhaps an increase in the volume of
the medulla itself, which would gradually occasion such a degree
of pressure against the sides of the unyielding canal, as must
eventually intercept the influence of the brain upon the inferior
portion of the medullary column, and upon the parts on which
the nerves of this portion are disposed.
From this review, and assuming that the morbid changes in
this disease may not be widely dissimilar from those which oc-
curred in the case of Count de Lordat, the chance of relief from
the proposed mode of treatment may appear to be sufficient to
warrant its trial.
In such a case then, at whatever period of the disease it might
be proposed to attempt the cure, blood should be first taken from
the upper part of the neck, unless conta-indicated by any par-
ticular circumstance. After which vesicatories should be ap-
plied to the same part, and a purulent discharge obtained by ap-
propriate use of the Sabine Liniment; having recourse to (p. 59)
the application of a fresh blister, when from the diminution of
the discharging surface, pus is not secreted in a sufficient quan-
tity. Should the blisters be found too inconvenient, or a suffi-
cient quantity of discharge not be obtained thereby, an issue of
at least an inch and a half in length might be established on each
side of the vertebral columna, in its superior part. These, it is
Medical Classics
994
presumed, would be best formed with caustic, and kept open
with any proper substance*.
Could it have been imagined that such considerable benefit:
indeed, that such astonishing cures, could have been effected by
issues in cases of Palsy of the lower extremities from diseased
spine? although satisfied with ascribing those cases to scrofulous
action, we are in fact as little informed respecting the nature of
the affection, inducing (p. 60) the carious state of the vertebrae,
as we are respecting the peculiar change of structure which takes
place in this disease. Equally uninformed are we also as to the
peculiar kind of morbid action, which takes place in the ligaments
of the joints; as well as that which takes place in different in-
stances of deep seated pains and affections of the parts con-
tained in the head, thorax, and abdomen, and in all which cases
the inducing of a purulent discharge in their neighbourhood is
so frequently productive of a cure. Experiment has not indeed
been yet employed to prove, but analogy certainly warrants the
hope, that similar advantages might be derived from the use of
the means enumerated, in the present disease. It is obvious,
that the chance of obtaining relief will depend in a great measure
on the period at which the means are employed. As in every
other disease, so here, the earlier the remedies are resorted to,
the greater will be the probability of success. But in this disease
there is one circumstance which demands particular attention;
the long period to which it may be extended. One of its pe-
culiar symptoms, Scelotyrbe festinans, may (p. 61) not occur
until the disease has existed ten or twelve years, or more; hence,
when looking for the period, within which our hopes of remedial
aid is to be limited; we may, guided by the slow progress of the
malady, extend it to a great length, when compared with that
within which we should be obliged to confine ourselves in most
other diseases.
* Cork, which has been hitherto neglected, appears to be very appropriate to this
purpose. It possesses lightness, softness, elasticity and sufficient firmness; and also
capable of being readily fashioned to any convenient form. The form which it seems
would be best adapted to the part, is that of an almond, or of the variety of bean called
scarlet bean; but at least an inch and a half in length.
Shaking Palsy 995
But it is much to be apprehended, as in many other cases,
that the resolution of the patients will seldom be sufficient to
enable them to perserve through the length of time which the
proposed process will necessarily require. As slow as is the prog-
ress of the disease, so slow in all probability must be the period
of the return to health. In most cases, especially in those in
which the disease has been allowed to exist long unopposed, it
may be found that all that art is capable of accomplishing, is
that of checking its further progress. Nor will this be regarded
as a trifle, when, by reference to the history of the disease, is
seen the train of harassing evils which would be thus avoided.
(p. 6a) But it seems as if there existed reason for hoping for
more. For supposing change of structure to have taken place,
it is extremely probable that this change may be merely increase
in mass or volume by interstitial addition, the consequence of
increased action in the minute vessels of the part. In that case,
should the instituting of a purulent dischage, in a neighbouring
part, act in the manner which we would presume it may — should
it by keeping up a constant discharge, not merely alter the de-
termination, but diminish the inordinate action of the vessels in
the diseased part; and at the same time excite the absorbents to
such increased action as may remove the added matter; there
will exist strong ground for hope, that a happy, though slow res-
toration to health, may be obtained.
Until we are better informed respecting the nature of this dis-
ease, the employment of internal medicines is scarcely warrant-
able; unless analogy should point out some remedy the trial of
which rational hope might authorize. Particular circumstances
indeed (p. 63) must arise in different cases, in which the aid of
medicine may be demanded: and the intelligent will never fail
to avail themselves of any opportunity of making trial of the in-
fluence of mercury, which has in so many instances, manifested
its power in correcting derangement of structure.
The weakened powers of the muscles in the affected parts is
so prominent a symptom, as to be very liable to mislead the in-
attentive, who may regard the disease as a mere consequence of
constitutional debility. If this notion be pursued, and tonic
Medical Classics
996
medicines, and highly nutritious diet be directed, no benefit is
likely to be thus obtained; since the disease depends not on gen-
eral weakness, but merely on the interruption of the flow of the
nervous influence to the affected parts.
It is indeed much to be regretted that this malady is generally
regarded by the sufferers in this point of view, so discouraging
to the employment of remedial means. Seldom occurring be-
fore the age of fifty, and frequently yielding but little inconven-
ience (p. 64) for several months, it is generally considered as the
irremediable diminution of the nervous influence, naturally re-
sulting from declining life; and remedies therefore are seldom
sought for.
Although unable to trace the connection by which a dis-
ordered state of the stomach and bowels may induce a morbid
action in a part of the medulla spinalis, yet taught by the in-
struction of Mr. Abemethy, little hesitation need be employed
before we determine on the probability of such occurrence. The
power, possessed by sympathy, of inducing such disordered ac-
tion in a distant part, and the probability of such disordered
action producing derangement of structure, can hardly be denied.
The following Case seems to prove, at least, that the mysterious
sympathetic influence which so closely simulates the forms of
other diseases, may induce such symptoms as would seem to
menace the formation of a disease not unlike to that which we
have been here treating of.
A. B. A man, 54 years of age, of temperate (p. 65) habits
and regular state of bowels, became gradually affected with
slight numbness and prickling, with a feeling of weakness in
in both arms, accompanied by a sense of fulness about the shoul-
ders, as if produced by the pressure of a strong ligature; and at
times a slight trembling of the hands. During the night, the
fullness, numbness, and prickling were much increased. The
appetite had been diminished for several weeks; and the ab-
domen, on being examined, felt as though containing consider-
able accumulation.
Before adopting any other measures, and as there appeared to
be no marks of vascular fulness, it was determined to empty the
Shaking Palsy 997
bowels. This was done effectually by moderate doses of calomel,
with the occasional help of Epsom salts; and in about ten days,
by these means alone, the complaints were entirely removed.
Before concluding these pages, it may be proper to observe
once more, that an important object proposed to be obtained by
them is, the leading of the attention of (p. 66) those who hu-
manely employ anatomical examination in detecting the causes
and nature of diseases, particularly to this malady. By their
benevolent labours its real nature may be ascertained, and ap-
propriate modes, of relief, or even of cure, pointed out.
To such researches the healing art is already much indebted
for the enlargement of its powers of lessening the evils of suffer-
ing humanity. Little is the public aware of the obligations it
owes to those who, led by professional ardour, and the dictates
of duty, have devoted themselves to these pursuits, under cir-
cumstances most unpleasant and forbidding. Every person of
consideration and feeling, may judge of the advantages yielded
by the philanthropic exertions of a HOWARD; but how few
can estimate the benefits bestowed on mankind, by the labours
of a MORGAGNI, HUNTER, or BAILLIE.
Finis
Index of Volume II
Addison, Thomas, Portrait, 232
Biography, 233
Bibliography, 234
“Disease,” 239
Brodie, Sir Benjamin Collins, Por-
trait, 882
Biography, 883
Bibliography, 885
“Abscess”, 900
“Disease of Joints,” 919
“Pile”, 929
“Tumor”, 941
Finlay, Carlos J., Portrait, 540
Biography, 541
Bibliography, 543
Mosquitoes and Yellow Fever,
569
Fitz, Reginald Heber, Portrait,
446
Biography, 447
Bibliography, 448
Vermiform Appendix, 459
Koch, Robert, Portrait, 714
Biography, 715
Bibliography, 720
Etiology of Anthrax, 745
Etiology of Tuberculosis, 821
Lister, Joseph, Portrait, 4
Biography, 5
Bibliography, 9
“Antiseptic Principles”, 28
McBurney, Charles, Portrait, 492
Biography, 493
Bibliography, 495
“Point”, 506
“Incision”, 533
McDowell, Ephraim, Portrait, 642
Biography, 643
Bibliography, 644
Extirpation of Diseased Ovaria,
6 S\
von Mikulicz-Radecki, Johann,
Portrait, 106
Biography, 107
Bibliography, no
“Disease,” 137
“Operation,” 188
Parkinson, James, Portrait, 956
Biography, 957
Bibliography, 958
“Disease or Syndrome,” 964
Sims, James Marion, Portrait, 662
Biography, 663
Bibliography, 665
Vesico-vaginal Fistula, 677
Withering, William, Portrait, 294
Biograph5 r , 2 95
Bibliography, 297
Account of the Foxglove, 305
MEDICAL
CLASSICS
VOLUME II
THE WILLIAMS & WILKINS COMPANY
BALTIMORE, MARYLAND
1 937-3 S
ttAVERLY PRESS, INC.
BALTIMORE, u. S A
Contents of Volume II
Lister, Joseph, Portrait
Biography
Bibliography
“Antiseptic Principles”
von Mikulicz-Radecki, Johann, Portrait
Biography
Bibliography
“Disease”
“Operation”
Addison, Thomas, Portrait
Biography
Bibliography
“Disease”
Withering, William, Portrait
Biography
Bibliography
Account of the Foxglove
Fitz, Reginald Heber, Portrait
Biography
Bibliography
Vermiform Appendix
McBurney, Charles, Portrait
Biography
Bibliography
“Point”
"Incision”
Finlay, Carlos J., Portrait
Biography
Bibliography
Mosquitoes and Yellow Fever
McDowell, Ephraim, Portrait
Biography
iii
4
*T
5
9
eS
ic6
icy
no
J 37
iSS
* 3 -
*39
*94
*95
297
335
■'6
4 * *7
~r*r/
-
*r*r -
459
- 9 -
493
495
fc6
533
54=
541
543
5^9
IV
Contents
McDowell, Ephraim, Bibliography 644
Extirpation of Diseased Ovaria 1 . 651
Sims, James Marion, Portrait 662
Biography 663
Bibliography 66 5
Vesico-vaginal fistula 677
Koch, Robert, Portrait 7*4
Biography 715
Bibliography 720
Etiology of Anthrax 745
Etiology of Tuberculosis 821
Brodie, Sir Benjamin Collins, Portrait 882
Biography 883
Bibliography 885
“Abscess” 900
“Disease of Joints” 9x9
“Pile” 929
“Tumor” 941 -
Parkinson, James, Portrait 956
Biography 957
Bibliography 958
“Disease or Syndrome” 964
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